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BACKGROUND Improvements in the Short Physical Performance Battery (SPPB) rather than exercise tolerance reportedly lead to favorable prognosis in elderly patients with acute decompensated heart failure (ADHF). However, about 50% of heart failure shows heart failure with preserved ejection fraction, safe and effective interventions to improve SPPB for these types remain unclear. In addition, although a standard cardiac rehabilitation (CR) program for heart failure is widely used in Japan, whether this is sufficient to improve SPPB in elderly patients with ADHF remains unclear. AIM This study was to evaluate whether the addition of multidisciplinary physical interventions to the standard CR program would prove effective for improving SPPB among elderly patients with ADHF regardless types of heart failure. DESING Randomized, prospective study. SETTING Patients admitted to our hospital due to ADHF in Japan. POPULATION Elderly patients with ADHF between March 2019 and March 2020 were randomized to two groups, an Intervention group and a Control group. METHODS The Control group performed standard CR. The Intervention group received balance training and resistance training and used a cycling ergometer in addition to the standard CR program. The primary outcome was the improvement in SPPB after CR. RESULTS Seventy-five patients with ADHF were divided into the two groups (Intervention group, n=36; Control group, n=39). At baseline, both groups showed low physical performance and a high prevalence of frailty. Intervention size effect was an improvement in SPPB score of +2.2 (+3.7±1.1 vs. +1.5±1.7; p