Older adults with heart failure (HF) are at high risk of potentially inappropriate medications (PIMs) during hospital discharge, yet real-world data from Asian populations remain limited. This study aimed to investigate the prevalence, spectrum and predictors of PIMs at discharge among older patients with HF in Eastern China. This retrospective cross-sectional study enrolled 468 patients aged ≥ 65 years with chronic HF hospitalized between 2022 and 2024. PIMs were identified according to 2023 American Geriatrics Society Beers Criteria. The primary outcome was PIM prevalence, and predictors were analyzed using multivariable logistic regression. PIMs are highly prevalent in older patients with HF at discharge. Polypharmacy, atrial fibrillation (AF) and renal impairment are the main risk factors. Targeted medication reconciliation and electronic medical record-based alerts are needed to reduce preventable drug-related harm. The overall prevalence of PIMs at discharge was 87.4% (409/468), with a mean of 2.4 ± 1.8 PIM instances per patient. Three independent predictors were identified: discharge medication count ≥ 7 (aOR = 3.45, 95% confidence interval (CI): 2.10-5.66), AF (adjusted odds ratio [aOR] = 2.98, 95% CI: 1.89-4.68), and eGFR < 45 mL/min/1.73m2 (aOR = 1.74, 95% CI : 1.05-2.88). A synergistic interaction between AF and polypharmacy further elevated PIM risk. Common PIMs included furosemide, rabeprazole and rivaroxaban.