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Background Acute decompensated heart failure (ADHF) with reduced ejection fraction often requires inotropic support. While dobutamine is commonly used, its safety and efficacy remain debated. Levosimendan has emerged as a potential alternative, with distinct pharmacological properties. This study aimed to compare the effects of levosimendan versus dobutamine on short-term clinical outcomes in patients with ADHF.Methods We performed a systematic search of PubMed (MEDLINE), Embase and the Cochrane Library to identify randomised controlled trials (RCTs) comparing levosimendan and dobutamine in adults with ADHF. The primary outcome was all-cause mortality within 30 days. Secondary outcomes included length of hospital stay and improvement in glomerular filtration rate. Meta-analyses were conducted using a random-effects model.Results Eight RCTs (n=1973) were included. Levosimendan significantly reduced 30-day mortality compared with dobutamine (OR 0.53, 95% CI 0.31 to 0.91; I² = 27%). Hospital stay was shortened by a mean of 2.4 days (95% CI –3.3 to –1.5), though heterogeneity was high. Limited data suggested renal function benefits. Certainty of evidence was moderate for mortality and very low for hospital stay.Conclusions Levosimendan reduced short-term mortality and hospital stay compared with dobutamine in patients with ADHF, although the certainty of evidence was moderate for mortality and very low for hospital stay. Larger trials are needed to confirm these findings.