OBJECTIVES: Acute decompensated heart failure (AHF) is a leading cause of hospital admission. The Randomized EValuation of Intravenous LeVosimendan Efficacy (REVIVE II) trial compared patients randomly assigned to levosimendan (levo) or placebo (SOC), each in addition to local standard AHF treatments. We report the REVIVE II economic analysis. METHODS: REVIVE II enrolled patients (N = 600) hospitalized for AHF remaining dyspneic at rest despite treatment with intravenous diuretics. Case report forms documented index hospital treatment (drug administration, procedures, days by care unit) as well as subsequent admissions during 90 day follow-up. These data were used to impute cost based on an econometric cost function derived from >100,000 AHF hospital billing records selected per REVIVE II inclusion criteria. RESULTS: Index admission mean length of stay (LOS) was shorter for the levo group compared with standard of care (SOC) (6.8 vs. 8.7 days, p=0.007) although ICU/CCU days were similar (levo 2.9, SOC 3.2, p=0.81). Excluding cost for levo, predicted mean (median) cost for the index admission was levo $13,590 (9,458), SOC $19,021 (10,692) with a difference of $5,431 (1,234) favoring levo (p=0.04). During follow-up through end of study day 90, no significant differences were observed in hospital admissions (p=0.67), inpatient days (p=0.81) or emergency visits (p=0.41). Subset analysis excluding patients with low baseline blood pressure also showed lower cost for the index admission for the levo group. Assuming an average price for levo in countries where is currently approved, incremental cost-effectiveness of levo relative to SOC in this subset is less than $1000 per year of life gained – a value well below accepted thresholds. CONCLUSION: In REVIVE II, patients treated with levo had shorter LOS and lower cost for the initial hospital admission relative to patients treated with SOC. When administered in accordance with the current label, levo is highly cost-effective relative to SOC.