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Conti N, Gatti M, Raschi E, Diemberger I, Potena L. Evidence and Current Use of Levosimendan in the Treatment of Heart Failure: Filling the Gap. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:3391-3409. [PMID: 34376973 PMCID: PMC8350150 DOI: 10.2147/dddt.s295214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/22/2021] [Indexed: 12/14/2022]
Abstract
Levosimendan is a distinctive inodilator combing calcium sensitization, phosphodiesterase inhibition and vasodilating properties through the opening of adenosine triphosphate-dependent potassium channels. It was first approved in Sweden in 2000 for the short-term treatment of acutely decompensated severe chronic heart failure when conventional therapy is not sufficient, and in cases where inotropic support is considered appropriate. After more than 20 years, clinical applications have considerably expanded across critical care and emergency medicine, and levosimendan is now under investigation in different cardiac settings (eg, septic shock, pulmonary hypertension) and for non-cardiac applications (eg, amyotrophic lateral sclerosis). This narrative review outlines key milestones in levosimendan history, by addressing regulatory issues, pharmacological peculiarities and clinical aspects (efficacy and safety) of a drug that did not receive great attention in the heart failure guidelines. A brief outlook to the ongoing clinical trials is also offered.
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Affiliation(s)
- Nicolina Conti
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Milo Gatti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCSS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Igor Diemberger
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luciano Potena
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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2
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Kaddoura R, Elmoheen A, Badawy E, Eltawagny MF, Seif MA, Bashir K, Salam AM. Vasoactive pharmacologic therapy in cardiogenic shock: a critical review. J Drug Assess 2021; 10:68-85. [PMID: 34350058 PMCID: PMC8293961 DOI: 10.1080/21556660.2021.1930548] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/12/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is an acute complex condition leading to morbidity and mortality. Vasoactive medications, such as vasopressors and inotropes are considered the cornerstone of pharmacological treatment of CS to improve end-organ perfusion by increasing cardiac output (CO) and blood pressure (BP), thus preventing multiorgan failure. OBJECTIVE A critical review was conducted to analyze the currently available randomized studies of vasoactive agents in CS to determine the indications of each agent and to critically appraise the methodological quality of the studies. METHODS PubMed database search was conducted to identify randomized controlled trials (RCTs) on vasoactive therapy in CS. After study selection, the internal validity of the selected studies was critically appraised using the three-item Jadad scale. RESULTS Nine studies randomized 2388 patients with a mean age ranged between 62 and 69 years, were identified. Seven of studies investigated CS in the setting of acute myocardial infarction (AMI). The studies evaluated the comparisons of norepinephrine (NE) vs. dopamine, epinephrine vs. NE, levosimendan vs. dobutamine, enoximone or placebo, and nitric oxide synthase inhibitors (NOSi) vs. placebo. The mean Jadad score of the nine studies was 3.33, with only three studies of a score of 5. CONCLUSIONS The evidence from the studies of vasoactive agents in CS carries uncertainties. The methodological quality between the studies is variable due to the inherent difficulties to conduct a study in CS. Vasopressors and inotropes continue to have a fundamental role given the lack of pharmacological alternatives.
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Affiliation(s)
- Rasha Kaddoura
- Heart Hospital Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Amr Elmoheen
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Ehab Badawy
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohamed A. Seif
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Bashir
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Amar M. Salam
- College of Medicine, QU Health, Qatar University, Doha, Qatar
- Adult Cardiology, Hamad Medical Corporation, Doha, Qatar
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3
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Ghionzoli N, Gentile F, Del Franco AM, Castiglione V, Aimo A, Giannoni A, Burchielli S, Cameli M, Emdin M, Vergaro G. Current and emerging drug targets in heart failure treatment. Heart Fail Rev 2021; 27:1119-1136. [PMID: 34273070 PMCID: PMC9197912 DOI: 10.1007/s10741-021-10137-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 12/11/2022]
Abstract
After initial strategies targeting inotropism and congestion, the neurohormonal interpretative model of heart failure (HF) pathophysiology has set the basis for current pharmacological management of HF, as most of guideline recommended drug classes, including beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists, blunt the activation of detrimental neurohormonal axes, namely sympathetic and renin–angiotensin–aldosterone (RAAS) systems. More recently, sacubitril/valsartan, a first-in-class angiotensin receptor neprilysin inhibitor, combining inhibition of RAAS and potentiation of the counter-regulatory natriuretic peptide system, has been consistently demonstrated to reduce mortality and HF-related hospitalization. A number of novel pharmacological approaches have been tested during the latest years, leading to mixed results. Among them, drugs acting directly at a second messenger level, such as the soluble guanylate cyclase stimulator vericiguat, or other addressing myocardial energetics and mitochondrial function, such as elamipretide or omecamtiv-mecarbil, will likely change the therapeutic management of patients with HF. Sodium glucose cotransporter 2 inhibitors, initially designed for the management of type 2 diabetes mellitus, have been recently demonstrated to improve outcome in HF, although mechanisms of their action on cardiovascular system are yet to be elucidated. Most of these emerging approaches have shifted the therapeutic target from neurohormonal systems to the heart, by improving cardiac contractility, metabolism, fibrosis, inflammation, and remodeling. In the present paper, we review from a pathophysiological perspective current and novel therapeutic strategies in chronic HF.
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Affiliation(s)
- Nicolò Ghionzoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Anna Maria Del Franco
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1 - 56124, Pisa, Italy
| | | | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alberto Giannoni
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1 - 56124, Pisa, Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Michele Emdin
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1 - 56124, Pisa, Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giuseppe Vergaro
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1 - 56124, Pisa, Italy.
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
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4
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Ghionzoli N, Sciaccaluga C, Mandoli GE, Vergaro G, Gentile F, D'Ascenzi F, Mondillo S, Emdin M, Valente S, Cameli M. Cardiogenic shock and acute kidney injury: the rule rather than the exception. Heart Fail Rev 2021; 26:487-496. [PMID: 33006038 PMCID: PMC8024234 DOI: 10.1007/s10741-020-10034-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2020] [Indexed: 01/21/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening condition of poor end-organ perfusion, caused by any cardiovascular disease resulting in a severe depression of cardiac output. Despite recent advances in replacement therapies, the outcome of CS is still poor, and its management depends more on empirical decisions rather than on evidence-based strategies. By its side, acute kidney injury (AKI) is a frequent complication of CS, resulting in the onset of a cardiorenal syndrome. The combination of CS with AKI depicts a worse clinical scenario and holds a worse prognosis. Many factors can lead to acute renal impairment in the setting of CS, either for natural disease progression or for iatrogenic causes. This review aims at collecting the current evidence-based acknowledgments in epidemiology, pathophysiology, clinical features, diagnosis, and management of CS with AKI. We also attempted to highlight the major gaps in evidence as well as to point out possible strategies to improve the outcome.
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Affiliation(s)
- N Ghionzoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Policlinico Le Scotte, Viale Bracci 16, Siena, Italy.
| | - C Sciaccaluga
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Policlinico Le Scotte, Viale Bracci 16, Siena, Italy
| | - G E Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Policlinico Le Scotte, Viale Bracci 16, Siena, Italy
| | - G Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - F Gentile
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - F D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Policlinico Le Scotte, Viale Bracci 16, Siena, Italy
| | - S Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Policlinico Le Scotte, Viale Bracci 16, Siena, Italy
| | - M Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - S Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Policlinico Le Scotte, Viale Bracci 16, Siena, Italy
| | - M Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Policlinico Le Scotte, Viale Bracci 16, Siena, Italy
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Guarracino F, Zima E, Pollesello P, Masip J. Short-term treatments for acute cardiac care: inotropes and inodilators. Eur Heart J Suppl 2020; 22:D3-D11. [PMID: 32431568 PMCID: PMC7225903 DOI: 10.1093/eurheartj/suaa090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute heart failure (AHF) continues to be a substantial cause of illness and death, with in-hospital and 3-month mortality rates of 5% and 10%, respectively, and 6-month re-admission rates in excess of 50% in a range of clinical trials and registry studies; the European Society of Cardiology (ESC) Heart Failure Long-Term Registry recorded a 1-year death or rehospitalization rate of 36%. As regards the short-term treatment of AHF patients, evidence was collected in the ESC Heart Failure Long-Term Registry that intravenous (i.v.) treatments are administered heterogeneously in the critical phase, with limited reference to guideline recommendations. Moreover, recent decades have been characterized by a prolonged lack of successful innovation in this field, with a plethora of clinical trials generating neutral or inconclusive findings on long-term mortality effects from a multiplicity of short-term interventions in AHF. One of the few exceptions has been the calcium sensitizer and inodilator levosimendan, introduced 20 years ago for the treatment of acutely decompensated chronic heart failure. In the present review, we will focus on the utility of this agent in the wider context of i.v. inotropic and inodilating therapies for AHF and related pathologies.
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Affiliation(s)
- Fabio Guarracino
- Dipartimento di Anestesia e Terapie Intensive, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Endre Zima
- Cardiac Intensive Care, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Piero Pollesello
- Critical Care Proprietary Products, CO, Orion Pharma, PO Box 65, FIN-02101 Espoo, Finland
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
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6
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Agostoni P, Farmakis DT, García-Pinilla JM, Harjola VP, Karason K, von Lewinski D, Parissis J, Pollesello P, Pölzl G, Recio-Mayoral A, Reinecke A, Yerly P, Zima E. Haemodynamic Balance in Acute and Advanced Heart Failure: An Expert Perspective on the Role of Levosimendan. Card Fail Rev 2019; 5:155-161. [PMID: 31768272 PMCID: PMC6848932 DOI: 10.15420/cfr.2019.01.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/09/2019] [Indexed: 12/20/2022] Open
Abstract
Acute and advanced heart failure are associated with substantial adverse short- and longer-term prognosis. Both conditions necessitate complex treatment choices to restore haemodynamic stability and organ perfusion, relieve congestion, improve symptoms and allow the patient to leave the hospital and achieve an adequate quality of life. Among the available intravenous vasoactive therapies, inotropes constitute an option when an increase in cardiac contractility is needed to reverse a low output state. Within the inotrope category, levosimendan is well suited to the needs of both sets of patients since, in contrast to conventional adrenergic inotropes, it has not been linked in clinical trials or wider clinical usage with increased mortality risk and retains its efficacy in the presence of beta-adrenergic receptor blockade; it is further believed to possess beneficial renal effects. The overall haemodynamic profile and clinical tolerability of levosimendan, combined with its extended duration of action, have encouraged its intermittent use in patients with advanced heart failure. This paper summarises the key messages derived from a series of 12 tutorials held at the Heart Failure 2019 congress organised in Athens, Greece, by the Heart Failure Association of the European Society of Cardiology.
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Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS Milan, Italy.,Department of Clinical Sciences and Community Health - Cardiovascular Section, University of Milan Milan, Italy
| | - Dimitrios T Farmakis
- University of Cyprus Medical School Nicosia, Cyprus.,Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Athens, Greece
| | - Jose M García-Pinilla
- Heart Failure and Familial Cardiopathies Unit, Cardiology Department, Hospital Universitario Virgen de la Victoria, IBIMA Málaga, Spain
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki University Hospital Helsinki, Finland
| | - Kristjan Karason
- Departments of Cardiology and Transplantation, Sahlgrenska University Hospital Gothenburg, Sweden
| | - Dirk von Lewinski
- Department of Cardiology, Myokardiale Energetik und Metabolismus Research Unit, Medical University Graz, Austria
| | - John Parissis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Athens, Greece.,Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens Athens, Greece
| | | | - Gerhard Pölzl
- Department of Internal Medicine III, Cardiology and Angiology Medical University of Innsbruck Austria
| | | | - Alexander Reinecke
- Klinik für Innere Medizin III, Kardiologie, Universitätskllinikum Schleswig-Holstein Kiel, Germany
| | - Patrik Yerly
- Service de Cardiologie, CHUV, Université de Lausanne Lausanne, Switzerland
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University Budapest, Hungary
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7
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Abstract
Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation.
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Affiliation(s)
- Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, Scotland.
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland.
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland.
| | - Jonathan R Dalzell
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, Scotland
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland
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8
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Kislitsina ON, Rich JD, Wilcox JE, Pham DT, Churyla A, Vorovich EB, Ghafourian K, Yancy CW. Shock - Classification and Pathophysiological Principles of Therapeutics. Curr Cardiol Rev 2019; 15:102-113. [PMID: 30543176 PMCID: PMC6520577 DOI: 10.2174/1573403x15666181212125024] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/11/2018] [Accepted: 12/10/2018] [Indexed: 01/10/2023] Open
Abstract
The management of patients with shock is extremely challenging because of the myriad of possible clinical presentations in cardiogenic shock, septic shock and hypovolemic shock and the limitations of contemporary therapeutic options. The treatment of shock includes the administration of endogenous catecholamines (epinephrine, norepinephrine, and dopamine) as well as various vasopressor agents that have shown efficacy in the treatment of the various types of shock. In addition to the endogenous catecholamines, dobutamine, isoproterenol, phenylephrine, and milrinone have served as the mainstays of shock therapy for several decades. Recently, experimental studies have suggested that newer agents such as vasopressin, selepressin, calcium-sensitizing agents like levosimendan, cardiac-specific myosin activators like omecamtiv mecarbil (OM), istaroxime, and natriuretic peptides like nesiritide can enhance shock therapy, especially when shock presents a more complex clinical picture than normal. However, their ability to improve clinical outcomes remains to be proven. It is the purpose of this review to describe the mechanism of action, dosage requirements, advantages and disadvantages, and specific indications and contraindications for the use of each of these catecholamines and vasopressors, as well as to elucidate the most important clinical trials that serve as the basis of contemporary shock therapy.
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Affiliation(s)
- Olga N Kislitsina
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States.,Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Jonathan D Rich
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Jane E Wilcox
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Duc T Pham
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Andrei Churyla
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Esther B Vorovich
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Kambiz Ghafourian
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Clyde W Yancy
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
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Vally S, Ferdynus C, Persichini R, Bouchet B, Braunberger E, Lo Pinto H, Martinet O, Vandroux D, Aujoulat T, Allyn J, Allou N. Impact of levosimendan on weaning from peripheral venoarterial extracorporeal membrane oxygenation in intensive care unit. Ann Intensive Care 2019; 9:24. [PMID: 30707314 PMCID: PMC6358626 DOI: 10.1186/s13613-019-0503-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/29/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Few data are available on the impact of levosimendan in refractory cardiogenic shock patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). The aim of this study was to evaluate the impact of levosimendan on VA-ECMO weaning in patients hospitalized in intensive care unit (ICU). METHODS This retrospective cohort study was conducted in a French university hospital from 2010 to 2017. All patients hospitalized in ICU undergoing VA-ECMO were consecutively evaluated. RESULTS A total of 150 patients undergoing VA-ECMO were eligible for the study. Thirty-eight propensity-matched patients were evaluated in the levosimendan group and 65 in the non-levosimendan group. In patients treated with levosimendan, left ventricular ejection fraction had increased from 21.5 ± 9.1% to 30.7 ± 13.5% (P < 0.0001) and aortic velocity-time integral from 8.9 ± 4 cm to 12.5 ± 3.8 cm (P = 0.002) 24 h after drug infusion. After propensity score matching, levosimendan was the only factor associated with a significant reduction in VA-ECMO weaning failure rates (hazard ratio = 0.16; 95% confidence interval 0.04-0.7; P = 0.01). Kaplan-Meier survival curves showed that survival rates at 30 days were 78.4% for the levosimendan group and 49.5% for the non-levosimendan group (P = 0.02). After propensity score matching analysis, the difference in 30-day mortality between the two groups was not significant (hazard ratio = 0.55; 95% confidence interval 0.27-1.10; P = 0.09). CONCLUSIONS Our results suggest that levosimendan was associated with a beneficial effect on VA-ECMO weaning in ICU patients.
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Affiliation(s)
- Shamir Vally
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Cyril Ferdynus
- Unité de Soutien Méthodologique, CHU de La Réunion, Saint-Denis, France.,INSERM, CIC 1410, Saint-Pierre, France
| | - Romain Persichini
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Bruno Bouchet
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Eric Braunberger
- Chirurgie cardiaque, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Hugo Lo Pinto
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Olivier Martinet
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - David Vandroux
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Thomas Aujoulat
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Jérôme Allyn
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Nicolas Allou
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France. .,Réanimation polyvalente, Hôpital Félix Guyon, Bellepierre, 97405, Saint-Denis, France.
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10
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Shang G, Yang X, Song D, Ti Y, Shang Y, Wang Z, Tang M, Zhang Y, Zhang W, Zhong M. Effects of Levosimendan on Patients with Heart Failure Complicating Acute Coronary Syndrome: A Meta-Analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2017; 17:453-463. [PMID: 28597399 DOI: 10.1007/s40256-017-0237-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The prognosis for patients with heart failure (HF), including cardiogenic shock (CS), complicating acute coronary syndrome (ACS) remains poor. OBJECTIVE This study aimed to review the relevant literature and evaluate whether levosimendan was associated with better clinical outcomes in these patients. METHODS We searched PubMed, EMBASE, and the Cochrane library databases for randomized controlled trials that investigated levosimendan compared with any control in patients with HF/CS complicating ACS. RESULTS A total of 1065 patients from nine trials were included in this study. Analysis showed that levosimendan significantly reduced total mortality and the incidence of worsening HF. In patients with HF-ACS, levosimendan was associated with reduced mortality. In patients with CS-ACS, no significant difference was observed between the two groups. Levosimendan contributed to significantly reduced mortality when compared with placebo, but no significant reduction was seen compared with dobutamine. Compared with controls, levosimendan decreased pulmonary capillary wedge pressure and systemic vascular resistance and increased cardiac index, with no significant difference observed between the groups in terms of heart rate. Levosimendan non-significantly increased the risk of hypotension but did not increase the risk of ischemic episodes, sinus tachycardia, atrial fibrillation, or ventricular arrhythmias. CONCLUSION Levosimendan appears to be a promising drug to reduce mortality and worsening HF in patients with HF/CS-ACS. It appears to provide hemodynamic benefit and was associated with an increased risk of hypotension.
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Affiliation(s)
- Guokai Shang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China
| | - Xinyan Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China
| | - Daijun Song
- Department of Emergency, Donggang People's Hospital, Rizhao, 276800, People's Republic of China
| | - Yun Ti
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China
| | - Yuanyuan Shang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China
| | - Zhihao Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China
- Department of Geriatrics, Qilu Hospital of Shandong University, Ji'nan, 250012, People's Republic of China
| | - Mengxiong Tang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China
- Department of Emergency, Qilu Hospital of Shandong University, Ji'nan, 250012, People's Republic of China
| | - Yun Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China
| | - Wei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China
| | - Ming Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, #107 West Wenhua Road, Ji'nan, 250012, People's Republic of China.
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Gustafsson F, Guarracino F, Schwinger RHG. The inodilator levosimendan as a treatment for acute heart failure in various settings. Eur Heart J Suppl 2017; 19:C2-C7. [PMID: 29249904 PMCID: PMC5932561 DOI: 10.1093/eurheartj/sux001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Levosimendan is an inodilator developed for treatment of acute heart failure. It was shown to enhance cardiac contractility, and to exert a vasodilatory effect in all vascular beds. In some trials, the use of levosimendan was associated with cardioprotective effects. These distinctive qualities may be relevant to its use in a range of acute heart failure settings and/or complications, including acute coronary syndromes and cardiogenic shock. It is conjectured that part of the benefit of levosimendan may arise from restoration of ventriculo-arterial coupling via optimization of the ratio of arterial to ventricular elastance and the transfer of mechanical energy. Full confirmation of the effectiveness of levosimendan is still awaited in many of these scenarios; however, the range of potential applications highlights both the versatility of levosimendan and the relative lack of proven interventions in many of these situations.
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Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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12
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Choc cardiogénique sévère : quel régime thérapeutique médicamenteux optimal ? Intérêt de l’association vasopresseurs–inotropes avec effet vasodilatateur. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1260-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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13
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Lemm H, Dietz S, Janusch M, Buerke M. Einsatz von Vasopressoren und Inotropika im kardiogenen Schock. Herz 2017; 42:3-10. [DOI: 10.1007/s00059-016-4525-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Sahu MK, Das A, Malik V, Subramanian A, Singh SP, Hote M. Comparison of levosimendan and nitroglycerine in patients undergoing coronary artery bypass graft surgery. Ann Card Anaesth 2016; 19:52-8. [PMID: 26750674 PMCID: PMC4900377 DOI: 10.4103/0971-9784.173020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Levosimendan a calcium ion sensitizer improves both systolic and diastolic functions. This novel lusitropic drug has predictable antiischemic properties which are mediated via the opening of mitochondrial adenosine triphosphate-sensitive potassium channels. This action of levosimendan is beneficial in cardiac surgical patients as it improves myocardial contractility, decreases systemic vascular resistance (SVR), and increases cardiac index (CI) and is thought to be cardioprotective. We decided to study whether levosimendan has any impact on the outcomes such as the duration of ventilation, the length of Intensive Care Unit (ICU) stay, and the hospital stay when compared with the nitroglycerine (NTG), which is the current standard of care at our center. Materials and Methods: Forty-seven patients undergoing elective coronary artery bypass surgery were randomly assigned to two groups receiving either levosimendan or NTG. The medications were started before starting surgery and continued until 24 h in the postoperative period. Baseline hemodynamic parameters were evaluated before beginning of the operation and then postoperatively at 3 different time intervals. N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) levels were also measured in both groups. Results: In comparison to the NTG group, the duration of ventilation and length of ICU stay were significantly less in levosimendan group (P < 0.05, P = 0.02). NT-proBNP level analysis showed a slow rising pattern in both groups and a statistically significant rise in the levels was observed in NTG group (P = 0.03, P = 0.02) in postoperative period when compared to levosimendan group of patients. Conclusion: Levosimendan treatment in patients undergoing surgical revascularization resulted in improved CI, decreased SVR and lower heart rate. And, thereby the duration of ventilation and length of ICU stay were significantly less in this group of patients when compared with NTG group.
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Affiliation(s)
- Manoj K Sahu
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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15
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 1-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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16
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 8029-- awyx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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17
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2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 1-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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18
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016; 37:2129-2200. [PMID: 27206819 DOI: 10.1093/eurheartj/ehw128] [Citation(s) in RCA: 8931] [Impact Index Per Article: 1116.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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19
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 and 1880=1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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20
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 8029-- #] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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21
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 8029-- -] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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22
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016. [DOI: 10.1093/eurheartj/ehw128 order by 1-- gadu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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23
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Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail 2016; 18:891-975. [DOI: 10.1002/ejhf.592] [Citation(s) in RCA: 4631] [Impact Index Per Article: 578.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Nieminen MS, Buerke M, Cohen-Solál A, Costa S, Édes I, Erlikh A, Franco F, Gibson C, Gorjup V, Guarracino F, Gustafsson F, Harjola VP, Husebye T, Karason K, Katsytadze I, Kaul S, Kivikko M, Marenzi G, Masip J, Matskeplishvili S, Mebazaa A, Møller JE, Nessler J, Nessler B, Ntalianis A, Oliva F, Pichler-Cetin E, Põder P, Recio-Mayoral A, Rex S, Rokyta R, Strasser RH, Zima E, Pollesello P. The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion. Int J Cardiol 2016; 218:150-157. [PMID: 27232927 DOI: 10.1016/j.ijcard.2016.05.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 01/09/2023]
Abstract
Acute heart failure and/or cardiogenic shock are frequently triggered by ischemic coronary events. Yet, there is a paucity of randomized data on the management of patients with heart failure complicating acute coronary syndrome, as acute coronary syndrome and cardiogenic shock have frequently been defined as exclusion criteria in trials and registries. As a consequence, guideline recommendations are mostly driven by observational studies, even though these patients have a particularly poor prognosis compared to heart failure patients without signs of coronary artery disease. In acute heart failure, and especially in cardiogenic shock related to ischemic conditions, vasopressors and inotropes are used. However, both pathophysiological considerations and available clinical data suggest that these treatments may have disadvantageous effects. The inodilator levosimendan offers potential benefits due to a range of distinct effects including positive inotropy, restoration of ventriculo-arterial coupling, increases in tissue perfusion, and anti-stunning and anti-inflammatory effects. In clinical trials levosimendan improves symptoms, cardiac function, hemodynamics, and end-organ function. Adverse effects are generally less common than with other inotropic and vasoactive therapies, with the notable exception of hypotension. The decision to use levosimendan, in terms of timing and dosing, is influenced by the presence of pulmonary congestion, and blood pressure measurements. Levosimendan should be preferred over adrenergic inotropes as a first line therapy for all ACS-AHF patients who are under beta-blockade and/or when urinary output is insufficient after diuretics. Levosimendan can be used alone or in combination with other inotropic or vasopressor agents, but requires monitoring due to the risk of hypotension.
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Affiliation(s)
| | - Michael Buerke
- Department of Internal Medicine II, St. Marien Hospital Siegen, Siegen, Germany
| | | | - Susana Costa
- Department of Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - István Édes
- Department of Cardiology, University of Debrecen, Debrecen, Hungary
| | - Alexey Erlikh
- Laboratory of Clinical Cardiology, Scientific Research Institute of Physical-Chemical Medicine, Moscow, Russia
| | - Fatima Franco
- Department of Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | | | - Vojka Gorjup
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and Intensive Care, University Hospital of Pisa, Pisa, Italy
| | | | - Veli-Pekka Harjola
- Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Trygve Husebye
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Igor Katsytadze
- Cardiological Intensive Care Unit, Alexandrovski Central Clinical Hospital, Kiev, Ukraine
| | - Sundeep Kaul
- Department of Intensive Care and Respiratory Medicine, The Royal Brompton & Harefield Hospitals NHS Trust, London, UK
| | - Matti Kivikko
- Critical Care Proprietary Products, Orion Pharma, Espoo, Finland
| | - Giancarlo Marenzi
- Cardiological Intensive Care Unit, Cardiological Center Monzino, Milan, Italy
| | - Josep Masip
- Department of Intensive Care Medicine, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
| | - Simon Matskeplishvili
- Department of Cardiology, University Clinic, Lomonosov Moscow State University, Moscow, Russia
| | - Alexandre Mebazaa
- Department of Anaesthesia and Burn and Critical Care, Saint-Louis-Lariboisière Hospital, AP-HP, University Paris-Diderot, Paris, France
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Denmark
| | - Jadwiga Nessler
- Jagiellonian University Medical College, Faculty of Medicine, Institute of Cardiology, Department of Coronary Heart Disease and Heart Failure, John Paul II Hospital, Cracow, Poland
| | - Bohdan Nessler
- Jagiellonian University Medical College, Faculty of Health Sciences, Division of Rescue Medicine, Department of Coronary Heart Disease and Heart Failure, John Paul II Hospital, Cracow, Poland
| | - Argyrios Ntalianis
- Department of Cardiology, Alexandra General Hospital of Athens, Athens, Greece
| | - Fabrizio Oliva
- Department of Cardiology II, Niguarda Ca' Granda Hospital, Milan, Italy
| | | | - Pentti Põder
- Department of Cardiology, North Estonia Medical Center, Tallinn, Estonia
| | | | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Richard Rokyta
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University Prague, Czech Republic
| | - Ruth H Strasser
- University of Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Piero Pollesello
- Critical Care Proprietary Products, Orion Pharma, Espoo, Finland
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Jia Z, Guo M, Zhang YQ, Liang HQ, Zhang LY, Song Y. Efficacy of intravenous levosimendan in patients with heart failure complicated by acute myocardial infarction. Cardiology 2014; 128:195-201. [PMID: 24751462 DOI: 10.1159/000357864] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 12/10/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the efficacy of a short-term intravenous infusion of levosimendan in patients with heart failure due to acute myocardial infarction (AMI). METHODS This was a randomized, single-center, single-blind study that included 160 patients. Patients were randomly divided into 2 groups: 1 received levosimendan (n = 80) and the other received placebo (n = 80). The study included multiple primary end points (death, myocardial ischemia or worsening heart at the 6 month follow-up) and used a composite outcome. RESULTS The primary end point rate in the levosimendan group was lower than that in placebo group (43.7 vs. 62.5%, HR 0.636, 95% CI 0.413-0.981, p = 0.041). Moreover, the mortality rate at 6 months was similar between the 2 groups (17.5 vs. 22.5%, HR 0.786, 95% CI 0.382-1.543, p = 0.458). There was a higher incidence of myocardial ischemia in the levosimendan group at 14 days than in the placebo group (11.2 vs. 7.5%, HR 1.510, p = 0.435), but between 15 and 180 days, it was significantly lower in the levosimendan group than in the placebo group (3.8 vs. 13.8%, HR 0.261, p = 0.036). CONCLUSION Short-term intravenous infusion of levosimendan appears to be more effective than placebo for treating patients with heart failure complicated by AMI.
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Affiliation(s)
- Zhi Jia
- TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, TEDA, Tianjin, China
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26
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Place des inotropes en réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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27
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Prise en charge du choc cardiogénique d’origine ischémique : mise au point. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0859-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Pierrakos C, Velissaris D, Franchi F, Muzzi L, Karanikolas M, Scolletta S. Levosimendan in critical illness: a literature review. J Clin Med Res 2014; 6:75-85. [PMID: 24578748 PMCID: PMC3935527 DOI: 10.14740/jocmr1702w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 01/30/2023] Open
Abstract
Levosimendan, the active enantiomer of simendan, is a calcium sensitizer developed for treatment of decompensated heart failure, exerts its effects independently of the beta adrenergic receptor and seems beneficial in cases of severe, intractable heart failure. Levosimendan is usually administered as 24-h infusion, with or without a loading dose, but dosing needs adjustment in patients with severe liver or renal dysfunction. Despite several promising reports, the role of levosimendan in critical illness has not been thoroughly evaluated. Available evidence suggests that levosimendan is a safe treatment option in critically ill patients and may reduce mortality from cardiac failure. However, data from well-designed randomized controlled trials in critically ill patients are needed to validate or refute these preliminary conclusions. This literature review is an attempt to synthesize available evidence on the role and possible benefits of levosimendan in critically ill patients with severe heart failure.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Universite Catholique de Louvain, Mont-Godinne University Hospital, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras School of Medicine, Patras, Greece
| | - Federico Franchi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luigi Muzzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 S. Euclid Avenue, St. Louis, MO, USA
| | - Sabino Scolletta
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
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Abstract
Despite advances in coronary revascularization and widespread use of primary percutaneous interventions, cardiogenic shock complicating an acute ST-elevation myocardial infarction (CSMI) remains a clinical challenge with high mortality rates. Conservative management with catecholamines is associated with serious limitations, including arrhythmias, increased myocardial oxygen consumption, and inadequate circulatory support. Clinicians have therefore turned to mechanical means of circulatory support. Circulatory assist systems for CSMI can be distinguished by the method of placement (i.e. percutaneous vs. surgical), the type of circulatory support (i.e. left ventricular, right ventricular, or biventricular pressure and/or volume unloading), and whether they are combined with extracorporal membrane oxygenation (ECMO). The percutaneous assist systems most commonly used in CSMI are the intra-aortic balloon pump (IABP), venoarterial ECMO, the Impella pump, and the TandemHeart. Decades of clinical studies and experience demonstrated haemodynamic improvement, including elevation of diastolic perfusion pressure and cardiac output. Recently, the large randomized IABP-Shock II Trial did not show a significant reduction in 30-day mortality in CSMI with IABP insertion. There are no randomized study data available for ECMO use in CSMI. Both the Impella pump and the TandemHeart did not reduce 30-day mortality when compared with IABP in small randomized controlled trials (RCTs). In conclusion, despite the need for effective mechanical circulatory support in CSMI, current devices, as tested, have not been demonstrated to improve short- or long-term survival rates. RCTs testing the optimal timing of device therapy and optimal device design are needed to improve outcomes in CSMI.
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Affiliation(s)
- Karl Werdan
- Department of Internal Medicine III, Heart Center, Martin-Luther-University Halle-Wittenberg, University Hospital Halle/Saale, Ernst-Grube-Str. 40, Halle/Saale 06120, Germany
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Liu Y, Liu B, Zhou H, Wei LQ. Continuous Levosimendan Infusion for Refractory Cardiogenic Shock Complicating Severe Acute Dichlorvos Poisoning. Am J Med Sci 2012; 344:166-70. [DOI: 10.1097/maj.0b013e318254490d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Therapie des infarktbedingten kardiogenen Schocks. Notf Rett Med 2012. [DOI: 10.1007/s10049-012-1627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Elahi MM, Lam J, Asopa S, Matata BM. Levosimendan Versus an Intra-aortic Balloon Pump in Adult Cardiac Surgery Patients With Low Cardiac Output. J Cardiothorac Vasc Anesth 2011; 25:1154-62. [DOI: 10.1053/j.jvca.2011.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Indexed: 11/11/2022]
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Jensen H, Eija R, Tuomas M, Jussi M, Fredrik Y, Kirsi A, Matti P, Kai K, Hannu T, Vesa A, Tatu J. Levosimendan decreases intracranial pressure after hypothermic circulatory arrest in a porcine model. SCAND CARDIOVASC J 2011; 45:307-15. [PMID: 21623682 DOI: 10.3109/14017431.2011.583356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Hypothermic circulatory arrest (HCA) provides an optimal operating field in aortic arch surgery, but it is associated with neurological complications. Levosimendan is an inotropic agent with clinical indications for open-heart surgery. Through peripheral vasodilatation, cardiac contractility enhancement and anti-inflammatory function it has a potential to improve cerebral protection after HCA. DESIGN Eighteen piglets were randomly assigned to a levosimendan group (n = 9) and a placebo group (n = 9) and underwent a 60-minute period of hypothermic circulatory arrest at 18°C. A levosimendan or placebo infusion (0.2 μg/kg/min) was commenced at the onset of anesthesia and continued for 24 hours. Animals were followed for one week and their neurological recovery was assessed daily. Finally the animals were electively sacrificed and their brain was harvested for histopathological examination. RESULTS Levosimendan decreased intracranial pressure during the experiment. There were no differences between the groups in terms of hemodynamic or metabolic data, brain metabolism, neurological recovery or histopathology of the cerebral tissue. In the levosimendan group, cardiac enzymes were slightly more elevated. CONCLUSIONS Levosimendan decreased intracranial pressure during the experiment, but in terms of cerebral metabolism, neurological recovery and histopathology of the brain tissue levosimendan did not improve brain protection in this experimental setting.
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Affiliation(s)
- Hanna Jensen
- Clinical Research Center, Oulu University Hospital, University of Oulu, Finland.
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Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s00390-011-0284-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Essential lessons in cardiogenic shock: epinephrine versus norepinephrine/dobutamine. Crit Care Med 2011; 39:583-4. [PMID: 21330855 DOI: 10.1097/ccm.0b013e318208e381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Buerke M, Lemm H, Dietz S, Werdan K. Pathophysiology, diagnosis, and treatment of infarction-related cardiogenic shock. Herz 2011; 36:73-83. [DOI: 10.1007/s00059-011-3434-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bridge to heart transplantation by a combination of levosimendan and biventricular pacing in a patient with end-stage refractory heart failure. COR ET VASA 2011. [DOI: 10.33678/cor.2011.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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[Therapeutic strategies in acute decompensated heart failure and cardiogenic shock]. Internist (Berl) 2011; 51:963-74. [PMID: 20652210 DOI: 10.1007/s00108-009-2537-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
As the population of elderly people is increasing, the number of patients requiring hospitalization for acute exacerbations is rising. Traditionally, these episodes of hemodynamic instability were viewed as a transient event characterized by systolic dysfunction, low cardiac output, and fluid overload. Diuretics, along with vasodilator and inotropic therapy, eventually became elements of standard care. In a multicenter observational registry (ADHERE--Acute Decompensated Heart Failure National Registry) of more than 275 hospitals, patients with acute decompensated heart failure were analyzed for their characteristics and treatments options. These data have shown that this population consists of multiple types of heart failure, various forms of acute decompensation, combinations of comorbidities, and varying degrees of disease severity. The challenges in the treatment require multidisciplinary approaches since patients typically are elderly and have complex combinations of comorbidities. So far only a limited number of drugs is currently available to treat the different groups. Over the past years it was shown that even "standard drugs" might be deleterious by induction of myocardial injury, worsening of renal function or increasing mortality upon treatment. Therefore, based on pathophysiology, different types of acute decompensated heart failure require specialized treatment strategies.
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Mathieu S, Craig G. Levosimendan in the Treatment of Acute Heart Failure, Cardiogenic and Septic Shock: A Critical Review. J Intensive Care Soc 2011. [DOI: 10.1177/175114371101200106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Levosimendan is a drug which increases the sensitivity of the heart to calcium and which opens potassium channels, resulting in inodilation. Clinical trial data from patients suffering from heart failure have demonstrated that it improves haemodynamics without increasing intra-cellular calcium or oxygen consumption. However, there is no consistent evidence of mortality reduction. This narrative review summarises the key trials of its use in acute heart failure, acute coronary syndrome, cardiogenic shock and septic shock.
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Affiliation(s)
- Steve Mathieu
- Steve Mathieu Locum Consultant in Critical Care and Anaesthesia, The Royal Bournemouth Hospital
| | - Gordon Craig
- Gordon Craig Consultant in Critical Care and Anaesthesia, Queen Alexandra Hospital, Portsmouth
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Importance of levosimendan on right ventricular function in patients with biventricular heart failure. Crit Care Med 2010. [DOI: 10.1097/ccm.0b013e3181d8c064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The syndrome of cardiogenic shock (CS) comprises a constellation of symptoms and signs that define a subset of patients with inadequate tissue perfusion secondary to myocardial dysfunction. Careful attention to and rapid identification of patients at risk for the development of CS and those with impending CS by both hospitalists and subspecialists will help to implement the time-sensitive therapy that it requires. Physicians should gain a familiarity with the underlying pathophysiology of CS and available diagnostic tools as well as the importance of vasopressor therapy, inotropic therapy, rapid reperfusion therapy, and mechanical support.
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Lazzeri C, Tarquini R, Valente S, Abbate R, Gensini GF. Emerging drugs for acute myocardial infarction. Expert Opin Emerg Drugs 2010; 15:87-105. [PMID: 20055689 DOI: 10.1517/14728210903405619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE OF THE FIELD The present review is aimed at going over the pharmacological profile (and the clinical impact) of the emerging drugs involved in the management of patients with ST-elevation myocardial infarction (STEMI) in order to provide the cardiologists who deal with these patients in the early phase with the most recent evidence on this topic. AREAS COVERED IN THIS REVIEW Anticoagulant and antiplatelet drugs are the main cornerstones of therapy in the treatment of STEMI patients undergoing primary percutaneous coronary intervention (PCI). The main issues that clinicians have to deal with are represented by balancing thrombotic and bleeding risks. In tailoring therapy, variables such as age, sex and previous disease should be taken into account, as well as ongoing complications (such as acute renal failure) that could affect hemostasis. Despite the well-established clinical benefits of antiplatelet agents, questions remain, mainly surrounding potential for variable platelet response, which are strictly related to non-genetic (i.e., diet, drug-drug interaction, clinical factors such as obesity, diabetes mellitus, and inflammation) and genetic determinants. WHAT THE READER WILL GAIN In their daily practice, cardiologists cannot abstract from the knowledge and updating on the ongoing research fields as well as the newly developed drugs, which they should frame in the very patient in the attempt to the develop a personalized medical strategy. These include also the pharmacological option(s) in the treatment of the reperfusion injury, the metabolic aspects and the stem cell therapy. TAKE HOME MASSAGE: In our opinion, the goal of ongoing research on the pharmacological approach to STEMI patients is a personalized medical strategy that relies on critical clinicians who merge newly developed acquisitions on this topic and a more complete, systemic and critical approach to the patient.
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Affiliation(s)
- Chiara Lazzeri
- University of Florence, Department of Heart and Vessels, Florence, Italy
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Superiority of levosimendan over dobutamine in right ventricle failure. Crit Care Med 2010. [DOI: 10.1097/ccm.0b013e3181c30df6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Right ventricular function in myocardial infarction complicated by cardiogenic shock: Improvement with levosimendan. Crit Care Med 2009; 37:3017-23. [PMID: 19661807 DOI: 10.1097/ccm.0b013e3181b0314a] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Levosimendan improves left ventricular hemodynamic function in patients with cardiogenic shock. However, its impact on right ventricular performance has not been determined. We compared the hemodynamic effects of levosimendan on left and right ventricular function in patients with intractable cardiogenic shock following myocardial infarction. DESIGN Observational hemodynamic study. SETTING Tertiary care center university hospital. PATIENTS Fifty-six patients with cardiogenic shock secondary to myocardial infarction were treated with percutaneous revascularization (including intra-aortic balloon pump when appropriate) and commenced on conventional inotropic therapy. INTERVENTION Twenty-five consecutive patients with cardiogenic shock due to myocardial infarction who had not improved sufficiently with conventional therapy (including dobutamine and norepinephrine) received levosimendan (as a bolus of 12 microg/kg per minute for 10 mins then 0.1 microg/kg per minute--0.2 mug/kg per minute) as "bail-out" therapy for 24 hrs while invasive hemodynamic parameters were recorded. MEASUREMENTS AND MAIN RESULTS Levosimendan therapy was associated with a significant increase in cardiac index from 2.1 +/- 0.1 to 3.0 +/- 0.2 L x min x m (p < .01). In addition, levosimendan enhanced right ventricular cardiac power index (0.14 +/- 0.19 to 0.18W +/- 0.12, p < .001), while pulmonary vascular resistance fell from 227.7 +/- 94.5 to 178.1 +/- 62.3 dyne x s x cm (p = .002). No significant change in central venous pressure or mean pulmonary artery pressure was observed. The observed hemodynamic improvement was sustained after the levosimendan infusion was stopped. CONCLUSIONS Levosimendan infusion for cardiogenic shock following acute myocardial infarction improved hemodynamic parameters of right ventricular performance. Furthermore, we describe the use of right ventricular cardiac power index as a hemodynamic parameter of right ventricular performance.
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Do it right? Crit Care Med 2009; 37:3168-9. [PMID: 19923936 DOI: 10.1097/ccm.0b013e3181b3a320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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den Uil CA, Lagrand WK, Valk SD, Spronk PE, Simoons ML. Management of Cardiogenic Shock: Focus on Tissue Perfusion. Curr Probl Cardiol 2009; 34:330-49. [DOI: 10.1016/j.cpcardiol.2009.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Greif M, Zwermann L, Reithmann C, Weis M. Levosimendan as rescue therapy in severe cardiogenic shock after ST-elevation myocardial infarction. ACTA ACUST UNITED AC 2009; 10:185-90. [DOI: 10.1080/17482940801935774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Levosimendan therapy in acute heart failure - experience from a specialized department of cardiology. COR ET VASA 2009. [DOI: 10.33678/cor.2009.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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