Objective To analyze the clinical characteristics and influencing factors in elderly patients with heart failure with improved ejection fraction (HFimpEF). Methods A total of 122 elderly patients with heart failure with reduced ejection fraction (HFrEF) admitted to Xingtai Central Hospital from June 2022 to June 2024 were selected as study subjects. Echocardiography was performed during follow-up at 3-6 months. According to the examination results of left ventricular ejection fraction (LVEF) and the changes from baseline, the patients were divided into an improved group (HFimpEF) and a persistent group. Clinical data and model for end-stage liver disease-Ⅺ (MELD-Ⅺ) scores were compared between the two groups. Data analysis was conducted using SPSS 27.0, and independent samples t-test, Mann-Whitney U test or Chi-square test was performed according to the data type. A logistic regression model was constructed to analyze the factors affecting the improvement of LVEF in elderly patients with HFrEF using the presence or absence of LVEF improvement (persistent=0, improved=1) as the dependent variable. Results This study included a total of 122 elderly HFrEF patients. Based on the results of follow-up echocardiography, 46 patients (37.70%) developed HFimpEF and were classified as the improved group, and the remaining 76 patients constituted the persistent group. The improved group had lower age, brain natriuretic peptide (BNP) level, proportion of patients with elevated MELD-XI score, left ventricular end-diastolic diameter (LVEDD), and left ventricular systolic diameter (LVESD) than the persistent group, but higher proportions of patients using spironolactone and β-blockers (all P<0.05). Logistic regression analysis revealed that the increases of MELD-Ⅺ score (OR=0.491,95%CI 0.283-0.851; P=0.012), LVEDD (OR=0.462,95%CI 0.314-0.679; P<0.001), and LVESD (OR=0.628,95%CI 0.497-0.792; P<0.001) were risk factors influencing the LVEF improvement in elderly HFrEF patients, and the use of spironolactone (OR=1.923,95%CI 1.218-3.036; P=0.005) and β-blockers (OR=1.721,95%CI 1.177-2.517; P=0.005) were protective factors. Conclusion The increases of MELD-Ⅺ score, LVEDD, and LVESD are risk factors influencing the development of HFrEF to HFimpEF in elderly patients, and the use of spironolactone and β-blockers are protective factors.