Objective To investigate the efficacy of sakubactril valsartan combined with ivabradine in the treatment of heart failure with reduced left ventricular ejection fraction （HFrEF） in elderly patients， as well as its effect on left ventricular remodeling， and identify the predictors of recurrent cardiac and cerebrovascular events. Methods A total of 144 HFrEF patients were randomly divided into observation group （n = 74， completed by 72 cases） and control group （n = 74， completed by 72 cases） using a random number table. The control group and the observation group were treated with ivabradine and sacubactril valsartan combined with ivabradine， respectively. After 6 months of treatment， the two groups were compared in terms of the clinical efficacy and cardiac output index （CI）， left ventricular myocardial mass index （LVMI）， tumor necrosis factor α （TNF-α），interleukin6 （IL-6） and troponin T（cTnT）， serum transforming growth factor-β1 （TGF-β1）， serum amino terminal brain natriuretic peptide precursor （NT-proBNP）， myocardial energy metabolism （MEE） and incidence of adverse reactions before and after treatment. Recurrent adverse cardiac and cerebrovascular events were assessed in both groups within 12 months of follow-up and a receiver operating characteristic curve （ROC） was used to select predictors of recurrent adverse cardiac and cerebrovascular events. Results After 6 months of treatment， the clinical efficacy of the observation group was better than that of control group （Z = -5.352， P < 0.001）； The total effective rate of the observation group was higher than that of control group （χ² = 4.765， P = 0.029）. CI， LVMI， TNF-α， IL-6， cTnT， TGF-β1， NT-proBNP， and MEE in both groups were significantly improved after treatment， and the improvement in these indicators was more significant in the observation group （all P < 0.05）. There was no significant difference in the incidence of adverse drug reactions between the two groups （χ² = 0.085， P = 0.771）. The levels of CI and LVMI were highly correlated with the levels of NT-proBNP， MEE， TNF-α， IL-6， cTnT and TGF-β1 in the two groups before treatment （all |r| > 0.90， P < 0.001）. Both NT-proBNP and cTnT had high predictive efficiency and they were complementary. Conclusions Sacubactril valsartan combined with ivabradine can improve cardiac function in patients with HFrEF， enhance clinical efficacy， delay and improve ventricular remodeling. Its mechanism may be related to its inhibition of inflammatory response and myocardial fibrosis， reduction of neuroendocrine factors， alleviation of myocardial damage， and reduction of myocardial energy metabolism， indicating good safety. NT-proBNP and cTnT can be used as predictors of the recurrent cardiac and cerebrovascular events.