Levosimendan improves diastolic and systolic function in failing human myocardium

Impaired Ca2+ Handling in Perfused Hypertrophic Hearts from Dahl Salt-Sensitive Rats

To clarify the correlation between intracellular Ca2+ dynamics and level of Ca2+-regulatory proteins, changes in Ca2+ handling and these proteins were investigated in a whole-heart experimental model of pressure-overload hypertrophy. We used 17-18-week-old male Dahl salt-sensitive rats (DS) and Dahl salt-resistant rats (DR) fed a high-salt diet. We monitored the fura-2 fluorescence ratio, an index of cytoplasmic Ca2+ concentration ([Ca2+]i), using a Ca2+ analyzer in a retrograde perfused heart. Left ventricular pressure (LVP) and an electrocardiogram were simultaneously recorded. Ca2+ handling was assessed by exposing the hearts to 2 min of low-Na+ (70 mmol/l) perfusion to produce an increase in [Ca2+]i (n = 6), which was sensitive to Ni2+, a blocker of the Na+/Ca2+ exchanger (NCX). In another series, the hearts were stimulated at 2.5 to 5 Hz to determine the Ca2+-force-frequency relationship (n = 6). DS rats showed marked cardiac hypertrophy without any signs of failure. The time-to-peak Ca2+ transient was prolonged in DS compared with that in DR during normal beating. During low-Na+ exposure, the time-to-peak diastolic [Ca2+]i (TTP) and the decay-time from peak [Ca2+]i (DT) were prolonged in DS compared with DR (TTP, 43.3 +/- 4.0 vs. 32.5 +/- 2.5 s, p < 0.05; DT, 70.0 +/- 8.8 vs. 29.2 +/- 2.7 s, p < 0.005). Following pretreatment with 10 mmol/l caffeine to inhibit sarcoplasmic reticulum (SR) function, TTP and DT were still prolonged in DS compared with DR (TTP, 64.2 +/- 9.7 vs. 37.0 +/- 5.8 s, p < 0.05; DT, 55.8 +/- 12.6 vs. 26.0 +/- 5.7 s, p < 0.05). The force (LVP)-frequency relationship was initially positive in DR but was negative at all times in DS (%LVP/2.5 Hz: DS, 90.3 +/- 2.0%; DR, 112.2 +/- 4.5%; p < 0.05). Elevation of diastolic [Ca2+]i (percent increase of baseline) was greater in DS than in DR with increased stimulation (5 Hz: DS, 80.7 +/- 6.7%; DR, 52.1 +/- 5.9%; p < 0.05). In Western blot analysis, the protein level of NCX was equivalent, whereas that of SR Ca2+ ATPase (SERCA2) was significantly decreased in DS compared with DR. These results suggest that slowing of cellular Ca2+ mobilization and removal is related to impaired Ca2+ handling in late-phase cardiac hypertrophy. Both the activity of the NCX and that of the SR may be affected. The SR dysfunction may be associated with change in protein level of SERCA2.

Molecular actions of drugs that sensitize cardiac myofilaments to Ca2+

Ca(2+)-sensitizers are inotropic agents that modify the response of myofilaments to Ca2+, and are potentially valuable drugs in the treatment of heart failure. These agents have diverse chemical structures, and in some cases also have effects as inhibitors of phosphodiesterase activity. Advantages of their actions include vasodilation combined with inotropic effects. Reduction in the amounts of Ca2+ required to activate the myofilaments also lowers the oxygen consumption required for Ca2+ transport, lowers the threat of arrhythmias, and may blunt Ca(2+)-dependent transcriptional and translational mechanisms leading to hypertrophy and failure. Although diastolic abnormalities and impaired relaxation were thought to be potential undesirable effects of Ca(2+)-sensitizers, studies of hearts beating in situ indicate that this may not be a major problem. We focus here on Ca(2+)-sensitizers that act on cardiac troponin C, the Ca2+ receptor that triggers activation of the actin-myosin interaction. Structural studies have identified a unique mode of Ca2+ signaling in cardiac troponin C that should aid in targeting drugs to the heart. Moreover, identification of docking sites of Ca(2+)-sensitizers on troponin C suggest new directions for rational drug design.

Levosimendan

Levosimendan, a pyridazinone-dinitrile derivative, is a calcium sensitiser with additional action on adenosine triphosphate (ATP)-sensitive potassium channels. It is used intravenously (IV) for the treatment of decompensated cardiac failure. At therapeutic doses, levosimendan exhibits enhanced contractility with no increase in oxygen demands. It also produces antistunning effects without increasing myocardial intracellular calcium concentrations or prolonging myocardial relaxation. Levosimendan also causes coronary and systemic vasodilation. In patients with decompensated congestive heart failure (CHF), IV levosimendan significantly reduced the incidence of worsening CHF or death. IV levosimendan significantly increased cardiac output or cardiac index and decreased filling pressure in the acute treatment of stable or decompensated CHF in large, double-blind, randomised trials and after cardiac surgery in smaller trials. Levosimendan is well tolerated, with the most common adverse events (headache, hypotension, nausea) being secondary to vasodilation. It has not been shown to be arrhythmogenic. Levosimendan has shown no clinically important pharmacokinetic interactions with captopril, felodipine, beta-blockers, digoxin, warfarin, isosorbide-5-mononitrate, carvedilol, alcohol (ethanol) or itraconazole.

Levosimendan: a parenteral calcium-sensitising drug with additional vasodilatory properties

Levosimendan (Simdax) is a new inodilator developed specifically for the treatment of decompensated heart failure. Its inotropic mechanism is based on calcium sensitisation of myofilaments and its vasodilator actions are related to the opening of ATP-dependent K-channels in the vasculature. Since the inotropic action of levosimendan does not require an increase in cytosolic free calcium, it is less arrhythmogenic than the conventional parenteral beta-agonist inotropes or PDE III inhibiting drugs. Due to the calcium-dependent binding of the drug to troponin C, levosimendan, unlike some other calcium-sensitising drugs, does not prolong diastolic relaxation of the myocytes but acts in synergy with the intramyocellular calcium levels. Furthermore, due to the anti-ischaemic effects of the K-channel opening in myocytes, levosimendan can be used during myocardial ischaemia. In clinical trials, levosimendan has dose-dependently increased cardiac output and decreased pulmonary capillary wedge pressure in patients with heart failure. On the other hand, it also increases heart rate and decreases blood pressure in these patients. In major clinical trials, where patients with decompensated heart failure have been treated with levosimendan, a reduction of overall mortality in comparison to placebo or dobutamine has been seen. This interesting finding should be verified in prospective outcome trials. In any case, the safety of levosimendan during myocardial ischaemia makes this drug valuable in the short-term treatment of decompensated heart failure.