Background <p>The aims of this study are twofold: (1) to investigate how intensive care unit (ICU) admission rates differ among heart failure (HF) subtypes [HF with preserved ejection fraction (HFpEF), HF with mildly reduced ejection fraction (HFmrEF), HF with reduced ejection fraction (HFrEF)] in geriatric patients undergoing hip fracture surgery, and (2) to evaluate and compare the predictive performance of the Orthopedic Physiological and Operative Severity Score (O-POSSUM), B-type natriuretic peptide (BNP) levels and Charlson comorbidity index (CCI) scores in determining ICU admission risk in this patient population.</p> Methods <p>This retrospective cohort study included 97 geriatric patients with HF who underwent hip fracture surgery between 2022 and 2024. Patients were categorized based on their left ventricular ejection fraction (LVEF) into HFpEF (≥ 50%), HFmrEF (40–49%), and HFrEF (&lt; 40%). Preoperative BNP values were retrieved from medical records, with BNP &gt; 35 pg/mL considered supportive of HF diagnosis. Demographic, clinical, and perioperative data were analyzed. Logistic regression was performed to determine independent predictors of ICU admission.</p> Results <p>ICU admission was required for 60.82% of the patients. HFrEF patients had the highest ICU admission rate (72%), followed by HFmrEF (45%) and HFpEF (25%) (<i>p</i> &lt; 0.001). HFmrEF patients showed perioperative risk behavior that paralleled HFrEF, indicating comparable vulnerability to perioperative complications. The O-POSSUM score and elevated BNP were significantly associated with ICU admission (O-POSSUM OR: 1.202, 95% CI: 1.064–1.359, <i>p</i> = 0.003; BNP per 100 pg/mL increase OR: 1.15, 95% CI: 1.02–1.29, <i>p</i> = 0.02), whereas the CCI did not reach statistical significance.</p> Conclusion <p>HFmrEF patients exhibit perioperative risk comparable to HFrEF, while O-POSSUM and BNP serve as reliable predictors of ICU admission in geriatric hip fracture surgery.</p>