Efficacy of levosimendan for acute decompensated heart failure with preserved ejection fraction in the elderly: a single-center retrospective analysis

Abstract Aims Current guidelines recommend medical treatment for heart failure with preserved ejection fraction (HFpEF) but do not address inotropic drug use during acute HF episodes. This real-world study aimed to evaluate the effects of levosimendan in elderly patients presenting with acute HFpEF. Methods We retrospectively identified patients aged ≥ 65 years hospitalized with acute HFpEF at our institution. Using propensity score matching (PSM), 160 patients were selected. Echocardiographic parameters and B-type natriuretic peptide (BNP) levels were assessed before and after levosimendan administration. Rehospitalization for heart failure (HF) and all-cause mortality were compared during follow-up. Results Multivariable analysis revealed significantly greater improvements in the levosimendan group for septal early diastolic mitral inflow velocity to mitral annular tissue velocity ratio (E/e’) (ΔE/e’: -2.4 ± 2.4 vs. -1.9 ± 2.1; t = -2.09, 95% CI: -0.76 to -0.02; p = 0.038) and New York Heart Association (NYHA) class median change: -1 (-1 to -0.25) vs. -1(-1 to 0); p = 0.048. No significant between-group differences were observed in ΔBNP, Δabsolute global longitudinal strain (ΔaGLS), Δleft ventricular ejection fraction (ΔLVEF), or hospital length of stay. Subgroup analyses demonstrated greater improvements in ΔaGLS and Δseptal E/e’ among patients with baseline aGLS < 16% or septal E/e’ ≥15. After a median follow-up of 12.5 months, composite outcomes of rehospitalization for HF and all-cause mortality did not differ significantly between groups (levosimendan 21 vs. control 23; Log-rank p = 0.095). Conclusions For older patients with acute HFpEF combined with more comorbidities, although levosimendan may transiently improve hemodynamics and functional capacity in the acute phase, it fails to demonstrate long-term prognostic benefits. The clinical benefit of this drug may be limited to select patients, and its clinical application may lack cost-effectiveness for broader application.