OBJECTIVES: Heart failure (HF) is the most frequent cause of hospitalization among US elderly. Despite limited evidence, current guidelines recommend the use of IV vasodilators in addition to IV loop diuretics (LD) for the treatment of acute HF (AHF) patients without hypotension. We investigated whether elderly patients hospitalized for AHF treated with IV LD combined with IV nitrates (NT) or IV nesiritide (NES) achieved better outcomes compared to those receiving IV-LD alone. METHODS: US hospital billing records (2007-2009) from the MarketScan Hospital Drug Database were analyzed. Patients ≥65 years old, with an AHF diagnosis and no evidence of hypotension and/or cardiogenic shock were included. Patients receiving IV-LD alone were paired with patients receiving IV-LD+NT and with patients receiving IV-LD+NES using propensity score matching. Outcomes included in-hospital mortality, length of stay (LOS), cost, and HF re-hospitalization rate. RESULTS: Compared to IV-LD alone (N=2,918), patients receiving IV-LD+NT (N=2,918; mean age 78.5 years, 44.7% male) had longer LOS (days, ICU: 1.5 vs. 2.2; total: 5.8 vs. 7.1, p<0.01 for both), higher costs ($8,810 vs. $13,387, p<0.01), but similar rates of mortality (2.2% vs. 2.5%, p>0.05) and one year HF re-hospitalization (37.2% vs. 37.4%, p>0.05). Compared to IV-LD alone (N=1,561), patients receiving IV-LD+NES (N=1,561; mean age 77.8 years, 56.7% male) had longer LOS (days, ICU: 1.9 vs. 2.4; total: 5.9 vs. 7.8, p<0.01 for both), higher costs ($8,775 vs. $13,040, p<0.01), higher one year HF re-hospitalization rates (38.2% vs. 41.8%, p<0.05), but similar mortality rates (2.8% vs. 3.5%, p>0.05).  CONCLUSIONS: This study amongst elderly AHF patients indicates that neither NT nor NES in addition to diuretics improve survival compared to diuretics alone, and are associated with longer LOS and higher hospitalization costs. These results raise the question as to whether currently utilized IV vasodilators are of value in the treatment of elderly AHF patients.