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.