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Arfaras-Melainis A, Ventoulis I, Polyzogopoulou E, Boultadakis A, Parissis J. The current and future status of inotropes in heart failure management. Expert Rev Cardiovasc Ther 2023; 21:573-585. [PMID: 37458248 DOI: 10.1080/14779072.2023.2237869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Heart failure (HF) is a complex syndrome with a wide range of presentations and acuity, ranging from outpatient care to inpatient management due to acute decompensated HF, cardiogenic shock or advanced HF. Frequently, the etiology of a patient's decompensation is diminished cardiac output and peripheral hypoperfusion. Consequently, there is a need for use of inotropes, agents that increase cardiac contractility, optimize hemodynamics and ensure adequate perfusion. AREAS COVERED Inotropes are divided into 3 major classes: beta agonists, phosphodiesterase III inhibitors and calcium sensitizers. Additionally, as data from prospective studies accumulates, novel agents are emerging, including omecamtiv mecarbil and istaroxime. The aim of this review is to summarize current data on the optimal use of inotropes and to provide an expert opinion regarding their current and future use in the management of HF. EXPERT OPINION The use of inotropes has long been linked to worsening mortality, tachyarrhythmias, increased myocardial oxygen consumption and ischemia. Therefore, individualized and evidence-based treatment plans for patients who require inotropic support are necessary. Also, better quality data on the use of existing inotropes is imperative, while the development of newer and safer agents will lead to more effective management of patients with HF in the future.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Ptolemaida, Greece
| | - Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Parissis
- Emergency Department, Heart Failure Unit, Attikon University Hospital, Athens, Greece
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Masarone D, Kittleson M, Pollesello P, Tedford RJ, Pacileo G. Use of Levosimendan in Patients with Pulmonary Hypertension: What is the Current Evidence? Drugs 2023; 83:195-201. [PMID: 36652192 DOI: 10.1007/s40265-022-01833-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 01/19/2023]
Abstract
Pulmonary hypertension, defined as an increase in mean arterial pressure > 20 mmHg, is a chronic and progressive condition with high mortality and morbidity. Drug therapy of patients with pulmonary hypertension is based on the distinctive pathophysiologic aspect that characterizes the different groups. However, recently, levosimendan, a calcium-sensitizing agent with inotropic, pulmonary vasodilator, and cardioprotective properties, has been shown to be an effective and safe therapeutic strategy for patients with pulmonary arterial hypertension (in addition to specific drugs) and pulmonary hypertension associated with left heart disease (as possible treatment). This review provides a comprehensive overview of the current evidence on the use of levosimendan in patients with pulmonary hypertension.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Via Leonardo Bianchi 1, 80100, Naples, Italy.
| | - Michelle Kittleson
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Piero Pollesello
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Via Leonardo Bianchi 1, 80100, Naples, Italy
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Masarone D, Kittleson MM, Pollesello P, Marini M, Iacoviello M, Oliva F, Caiazzo A, Petraio A, Pacileo G. Use of Levosimendan in Patients with Advanced Heart Failure: An Update. J Clin Med 2022; 11:jcm11216408. [PMID: 36362634 PMCID: PMC9659135 DOI: 10.3390/jcm11216408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/04/2022] [Accepted: 10/26/2022] [Indexed: 11/25/2022] Open
Abstract
Levosimendan is an inodilator drug that, given its unique pharmacological actions and safety profile, represents a viable therapeutic option in patients with heart failure with reduced ejection fraction in the advanced stage of the disease (advHFrEF). Pulsed levosimendan infusion in patients with advHFrEF improves symptoms and clinical and hemodynamic status, prevents recurrent hospitalizations, and enables optimization of guidelines-directed medical therapy. Furthermore, considering its proprieties on right ventricular function and pulmonary circulation, levosimendan could be helpful for the prevention and treatment of the right ventricular dysfunction post-implanting a left ventricular assist device. However, to date, evidence on this issue is scarce and has yielded mixed results. Finally, preliminary experiences indicate that treatment with levosimendan at scheduled intervals may serve as a “bridge to transplant” strategy in patients with advHFrEF. In this review, we summarized the clinical pharmacology of levosimendan, the available evidence in the treatment of patients with advHFrEF, as well as a hypothesis for its use in patients with advanced heart failure with preserved ejection fraction.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-0817065163; Fax: +39-0817062674
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA 90048, USA
| | | | - Marco Marini
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I-GM Lancisi-G Salesi, 60126 Ancona, Italy
| | - Massimo Iacoviello
- Intensive Cardiac Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Fabrizio Oliva
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Angelo Caiazzo
- Heart Transplant Unit, Department of Cardiac Surgery and Transplant, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplant, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, 80131 Naples, Italy
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Rottmann FA, Breiden AK, Bemtgen X, Welte T, Supady A, Wengenmayer T, Staudacher DL. Levosimendan in acute heart failure with severely reduced kidney function, a propensity score matched registry study. Front Cardiovasc Med 2022; 9:1027727. [PMID: 36337866 PMCID: PMC9631470 DOI: 10.3389/fcvm.2022.1027727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/06/2022] [Indexed: 11/14/2022] Open
Abstract
Background Patients with heart failure frequently present with kidney dysfunction. Kidney function is relevant, as prognosis declines with reduced kidney function and potentially beneficial drugs like levosimendan are contraindicated for missing safety data. Materials and methods A single-center retrospective registry study was conducted including all patients receiving levosimendan on a medical intensive care unit between January 2010 and December 2019. Exclusion criteria were a follow-up less than 24 h or missing glomerular filtration rate (eGFR) before administration of levosimendan. The first course of treatment was evaluated. Patients were stratified by eGFR before drug administration and the primary endpoint was a composite of supraventricular-, ventricular tachycardia and death within 7 days after administration of levosimendan. An internal control group was created by propensity score matching. Results A total of 794 patients receiving levosimendan were screened and 368 unique patients were included. Patients were predominantly male (73.6%) and median age was 63 years. Patients were divided by eGFR into three groups: >60 ml/min/1.73 m2 (n = 110), 60–30 ml/min/1.73 m2 (n = 130), and <30 ml/min/1.73 m2 (n = 128). ICU survival was significantly lower in patients with lower eGFR (69.1, 57.7, and 50.8%, respectively, p = 0.016) and patients with lower eGFR were significantly older and had significantly more comorbidities. The primary combined endpoint was reached in 61.8, 63.1, and 69.5% of subjects, respectively (p = 0.396). A multivariate logistic regression model suggested only age (p < 0.020), extracorporeal membrane oxygenation (p < 0.001) or renal replacement therapy (p = 0.028) during day 1–7 independently predict the primary endpoint while kidney function did not (p = 0.835). A propensity score matching of patients with eGFR < 30 and >30 ml/min/1.73 m2 based on these predictors of outcome confirmed the primary endpoint (p = 0.886). Conclusion The combined endpoint of supraventricular-, ventricular tachycardia and death within 7 days was reached at a similar rate in patients independently of kidney function. Prospective randomized trials are warranted to clarify if levosimendan can be used safely in severely reduced kidney function.
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Affiliation(s)
- Felix Arne Rottmann
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Medicine IV – Nephrology and Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
- *Correspondence: Felix Arne Rottmann,
| | - Ann Katrin Breiden
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Welte
- Department of Medicine IV – Nephrology and Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
- Friedrich Miescher Institute for Biomedical Research, Basel, Switzerland
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid Leander Staudacher
- Interdisciplinary Medical Intensive Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Zhang H, Jiang L, Fu R, Qin P, Zhang X, Tian T, Feng GX, Yang YM. Impact of levosimendan on efficacy and renal function in acute heart failure according to renal function: A perspective, multi-center, real-world registry. Front Cardiovasc Med 2022; 9:986039. [PMID: 36337876 PMCID: PMC9626812 DOI: 10.3389/fcvm.2022.986039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/08/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Acute heart failure (AHF) is associated with high mortality. Levosimendan, an inodilator, has proved to increase cardiac output and exert renoprotective effect in AHF. Our aim was to investigate the efficacy and renoprotective effects of levosimendan in patients with AHF and different renal function. Methods This is a prospective, observational, multi-center registry. Patients admitted with AHF between June 2020 and May 2022 and treated with levosimendan during the hospital stay were included. Baseline characteristics, laboratory tests, electrocardiogram (ECG), chest X-ray, echocardiography, and treatment were collected. A 5-point Likert scale was used to document patients' baseline dyspnea. The estimated glomerular filtration rate (eGFR) was calculated by means of the Modification of Diet in Renal Disease equation. After levosimendan infusion, patients underwent assessment of degree of dyspnea, and levels of brain-type natriuretic peptide (BNP) /N-terminal pro-BNP (NT-pro BNP), and eGFR repeatedly. Results Among 789 AHF patients who received levosimendan treatment in this study, 33.0 % were female, mean age was 64.9 ± 16.8 years, and mean eGFR was 72.6 ± 32.5 ml/min/m2. The mean score of dyspnea was 3.0 ± 1.0 using 5-point Likert scale before levosimendan infusion. Dyspnea improved in 68.7% patients at 6h after infusion of levosimendan, and in 79.5% at 24 h. Lower eGFR was associated with lower efficacy rate after 6h infusion (71.7, 70.7, 65.2, and 66.0%, respectively) and after 24 h infusion (80.5, 81.4, 76.2, and 77.8%, respectively). The levels of BNP or NT-pro BNP were also decreased after levosimendan treatment, and in each eGFR category. Levels of eGFR increased from baseline (72.6 ± 32.5 ml/min/m2) to 12–24h (73.8 ± 33.5 ml/min/m2) and 24–72h (75.0 ± 33.4 ml/min/m2) after starting treatment (p < 0.001). However, the eGFR levels increased only in patients with eGFR lower than 90.0 ml/min/m2. Conclusions In AHF patients who received levosimendan, degree of dyspnea and levels of BNP or NT-pro BNP were significantly improved, especially in patients with higher eGFR levels. However, levosimendan infusion increase eGFR only in AHF patients with renal dysfunction.
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The importance of pharmacokinetics, pharmacodynamic and repetitive use of levosimendan. Biomed Pharmacother 2022; 153:113391. [DOI: 10.1016/j.biopha.2022.113391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022] Open
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Kipka H, Tomasi R, Hübner M, Liebchen U, Hagl C, Wanner KT, Mannell H, Höfner G. Simultaneous LC-ESI-MS/MS Quantification of Levosimendan and Its Metabolites for Therapeutic Drug Monitoring of Cardiac Surgery Patients. Pharmaceutics 2022; 14:pharmaceutics14071454. [PMID: 35890349 PMCID: PMC9319272 DOI: 10.3390/pharmaceutics14071454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Levosimendan is used in severe chronic cardiac insufficiency, also within the peri-operative setting. Real-life pharmacokinetic data in surgical patients is lacking, making therapeutic drug monitoring (TDM) of levosimendan, its pharmacologically active metabolite OR-1896, and its intermediate OR-1855 important. A simultaneous highly sensitive quantification of levosimendan and its metabolites in small-volume samples has not yet been described. Here, levosimendan (LLOQ 0.450 nM), OR-1896, and OR-1855 (LLOQ both 1.0 nM) were successfully quantified by LC-ESI-MS/MS after liquid-liquid extraction in 300 µL of blood. A short C8 column under reversed-phase conditions enabled simultaneous and fast quantification of levosimendan in the negative and the metabolites in the positive ionization mode in a single run within 2 min. Interestingly and unexpectedly, constitutional isomers of levosimendan metabolites with identical mass transitions and similar retention times were observed in surgical patients’ samples, which we identified as the metamizole metabolites 4-aminoantipyrine and 4-acetamidoantipyrine. A longer C8 column and a modified mobile phase enabled selective quantification of all analytes in a single run within 7 min. We developed, validated, and applied highly sensitive LC-ESI-MS/MS methods for simultaneous quantification of levosimendan and its metabolites, enabling efficient TDM of cardiac surgery patients even with additional metamizole administration.
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Affiliation(s)
- Hannah Kipka
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany;
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
- Correspondence:
| | - Roland Tomasi
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
| | - Max Hübner
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
- Walter Brendel Center of Experimental Medicine, LMU Munich, 81377 Munich, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany;
- DZHK (German Centre of Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Klaus T. Wanner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität, 81377 Munich, Germany; (K.T.W.); (G.H.)
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany;
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
| | - Georg Höfner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität, 81377 Munich, Germany; (K.T.W.); (G.H.)
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Renal Impairment in Patients With Acute Heart Failure: Are Inotropes Safe? J Cardiovasc Pharmacol 2022; 79:772-773. [PMID: 35383633 DOI: 10.1097/fjc.0000000000001269] [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: 11/25/2022]
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Comparative Effectiveness and Safety of Milrinone and Levosimendan as Initial Inotrope Therapy in Patients With Acute Heart Failure With Renal Dysfunction. J Cardiovasc Pharmacol 2022; 79:781-790. [PMID: 35507915 DOI: 10.1097/fjc.0000000000001255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Levosimendan and milrinone are 2 effective inotropic drugs used to maintain cardiac output in acute heart failure (AHF). Using data from patients with AHF with and without abnormal renal function, we performed this single-center, retrospective cohort study to compare the effectiveness and safety of milrinone and levosimendan for the initial management of AHF. Patients admitted for heart failure between December 2016 and September 2019 who received levosimendan or milrinone as initial inotrope therapy in the cardiology department were identified. A total of 436 levosimendan and 417 milrinone patients with creatinine clearance (CrCl) ≥30 mL/min and 50 levosimendan and 71 milrinone patients with CrCl <30 mL/min or on dialysis were included. The primary outcome was a composite of changes in clinical status at 15 and 30 days after initial inotrope therapy discontinuation. Between subgroups of patients with CrCl ≥30 mL/min, there were no significant differences in primary outcomes; milrinone was associated with more frequent hypotension and cardiac arrhythmias during the infusion period (P < 0.01), while levosimendan was associated with more frequent cardiac arrhythmias within 48 hours after discontinuation (P < 0.05). Of the patients with CrCl <30 mL/min or on dialysis, more initial levosimendan than milrinone patients and those who switched to alternative inotropes experienced clinical worsening at 15 days and 30 days (P < 0.05). According to our results, patients with AHF with severe renal dysfunction should avoid initial inotrope therapy with levosimendan.
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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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Long YX, Cui DY, Kuang X, Hu Y, Hu S, Wang CP, Liu ZZ. Effect of levosimendan on renal function in background of left ventricular dysfunction: a meta-analysis of randomized trials. Expert Opin Drug Saf 2021; 20:1411-1420. [PMID: 34214005 DOI: 10.1080/14740338.2021.1951700] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Levosimendan, an inotrope, is widely used in the management of heart failure (HF) and cardiac surgery, but it remains uncertain whether levosimendan can improve renal function in patients with left ventricular dysfunction (LVD). METHODS PubMed, Embase, and Cochrane CENTRAL from the inception to June 2020 were systematically screened for randomized controlled trials (RCTs) to investigate whether levosimendan offers kidney-related advantages in cardiovascular patients with LVD. We pooled the effects using a random-effect model. RESULTS Twenty-eight studies enrolling 5069 patients were included. Levosimendan reduced the sCr (SMD -0.28, 95% CI (-0.48, -0.09), P = 0.005, I2 = 52.5%, high quality) and the risk of ARF (relative risk 0.75, 95%CI (0.60, 0.95), P = 0.017, I2 = 11.3%, moderate-quality) in patients with LVD compared with control group. The reduction of sCr was more pronounced in patients with a relatively higher baseline sCr level. For secondary outcomes, levosimendan therapy was associated with the improvement of GFR (SMD 0.32, 95%CI (-0.05, 0.68), P = 0.092, I2 = 55.1%, low-quality) and urine output (SMD 0.42, 95%CI (0.06, 0.79), P = 0.024, I2 = 50.0%, very low-quality), but there was no significant reduction in BUN (SMD -0.14, 95%CI (-0.97, 0.70), P = 0.774, I2 = 77.9%, very low-quality). CONCLUSIONS Levosimendan might improve renal function of patients with LVD.
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Affiliation(s)
- Yu-Xiang Long
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Di-Yu Cui
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xue Kuang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chun-Ping Wang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zeng-Zhang Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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12
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Chan CC, Lee KT, Ho WJ, Chan YH, Chu PH. Levosimendan use in patients with acute heart failure and reduced ejection fraction with or without severe renal dysfunction in critical cardiac care units: a multi-institution database study. Ann Intensive Care 2021; 11:27. [PMID: 33555483 PMCID: PMC7869075 DOI: 10.1186/s13613-021-00810-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 01/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background Acute heart failure is a life-threatening clinical condition. Levosimendan is an effective inotropic agent used to maintain cardiac output, but its usage is limited by the lack of evidence in patients with severely abnormal renal function. Therefore, we analyzed data of patients with acute heart failure with and without abnormal renal function to examine the effects of levosimendan. Methods We performed this retrospective cohort study using data from the Chang Gung Research Database (CGRD) of Chang Gung Memorial Hospital (CGMH). Patients admitted for heart failure with LVEF ≤ 40% between January 2013 and December 2018 who received levosimendan or dobutamine in the critical cardiac care units (CCU) were identified. Patients with extracorporeal membrane oxygenation (ECMO) were excluded. Outcomes of interest were mortality at 30, 90, and 180 days after the cohort entry date. Results There were no significant differences in mortality rate at 30, 90, and 180 days after the cohort entry date between the levosimendan and dobutamine groups, or between subgroups of patients with an estimated glomerular filtration rate (eGFR) ≥ 30 mL/min/1.73 m2 and eGFR < 30 mL/min/1.73 m2 or on dialysis. The results were consistent before and after propensity score matching. Conclusions Levosimendan did not increase short- or long-term mortality rates in critical patients with acute heart failure and reduced ejection fraction compared to dobutamine, regardless of their renal function. An eGFR less than 30 mL/min/1.73 m2 was not necessarily considered a contraindication for levosimendan in these patients.
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Affiliation(s)
- Cze-Ci Chan
- Department of Cardiology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Tso Lee
- Department of Cardiology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wan-Jing Ho
- Department of Cardiology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Hsin Chan
- Department of Cardiology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Zangrillo A, Alvaro G, Pisano A, Guarracino F, Lobreglio R, Bradic N, Lembo R, Gianni S, Calabrò MG, Likhvantsev V, Grigoryev E, Buscaglia G, Pala G, Auci E, Amantea B, Monaco F, De Vuono G, Corcione A, Galdieri N, Cariello C, Bove T, Fominskiy E, Auriemma S, Baiocchi M, Bianchi A, Frontini M, Paternoster G, Sangalli F, Wang CY, Zucchetti MC, Biondi-Zoccai G, Gemma M, Lipinski MJ, Lomivorotov VV, Landoni G. A randomized controlled trial of levosimendan to reduce mortality in high-risk cardiac surgery patients (CHEETAH): Rationale and design. Am Heart J 2016; 177:66-73. [PMID: 27297851 DOI: 10.1016/j.ahj.2016.03.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 03/30/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Patients undergoing cardiac surgery are at risk of perioperative low cardiac output syndrome due to postoperative myocardial dysfunction. Myocardial dysfunction in patients undergoing cardiac surgery is a potential indication for the use of levosimendan, a calcium sensitizer with 3 beneficial cardiovascular effects (inotropic, vasodilatory, and anti-inflammatory), which appears effective in improving clinically relevant outcomes. DESIGN Double-blind, placebo-controlled, multicenter randomized trial. SETTING Tertiary care hospitals. INTERVENTIONS Cardiac surgery patients (n = 1,000) with postoperative myocardial dysfunction (defined as patients with intraaortic balloon pump and/or high-dose standard inotropic support) will be randomized to receive a continuous infusion of either levosimendan (0.05-0.2 μg/[kg min]) or placebo for 24-48 hours. MEASUREMENTS AND MAIN RESULTS The primary end point will be 30-day mortality. Secondary end points will be mortality at 1 year, time on mechanical ventilation, acute kidney injury, decision to stop the study drug due to adverse events or to start open-label levosimendan, and length of intensive care unit and hospital stay. We will test the hypothesis that levosimendan reduces 30-day mortality in cardiac surgery patients with postoperative myocardial dysfunction. CONCLUSIONS This trial is planned to determine whether levosimendan could improve survival in patients with postoperative low cardiac output syndrome. The results of this double-blind, placebo-controlled randomized trial may provide important insights into the management of low cardiac output in cardiac surgery.
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The use of levosimendan in children with cancer with severe acute cardiac dysfunction: case series and a review of the literature. Cardiol Young 2014; 24:524-7. [PMID: 23659288 DOI: 10.1017/s1047951113000565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report the use of levosimendan in two febrile, neutropenic children with cancer - one post bone marrow transplant - with acute heart failure following chemotherapy. Initial management with epinephrine, milrinone, and diuresis was unsuccessful. Infusion of levosimendan without a loading dose was added to the ongoing heart failure therapy, which resulted in persistent symptomatic and echocardiographic improvement without major side effects.
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Barisin S, Djuzel V, Barisin A, Rudez I. Levosimendan reverses right-heart failure in a 51-year-old patient after heart transplantation. Wien Klin Wochenschr 2014; 126:495-9. [PMID: 24652017 DOI: 10.1007/s00508-014-0528-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 02/18/2014] [Indexed: 11/30/2022]
Abstract
Primary graft failure in the early postoperative period after heart transplantation, remains a main cause of a poor outcome. Current treatment options include pharmacological (catecholamines and phosphodiesterase inhibitors) and mechanical assist device support. Pharmacological support with catecholamines is related to elevated myocardial oxygen consumption and regional hypoperfusion leading to organ damage. On the other hand, levosimendan, as a calcium-sensitizing agent increases cardiac contractility without altering intracellular Ca(2+) levels and increase in oxygen demand. We present a case of a 51-year-old man, who was suffering from acute right-heart failure in the early postoperative period after heart transplantation. As a rescue therapy at the late stage of a low cardiac output state, levosimendan was started as continuous infusion at 0.1 μg/kg/min for 12 h and thereafter, at 0.2 μg/kg/min for the following 36 h. Levosimendan demonstrated an advanced pharmacological option as was portrayed in this case, where the right ventricle was under a prolonged severe depression and acutely overloaded after heart transplantation.
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Affiliation(s)
- Stjepan Barisin
- Clinical Department of Cardiovascular Anesthesia and Intensive Care, University Department of Anesthesiology, Resuscitation and Intensive Care, Dubrava University Hospital, Av. G. Suska 6, 10000, Zagreb, Croatia,
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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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Toller W, Guarracino F, Landoni G. Reply to Carev et al: “Useful Supplement to the Best Practice of Using Levosimendan in Cardiac Surgery Patients: 2.5 mg Intravenous Bolus for Cardiopulmonary Resuscitation During Perioperative Cardiac Arrest”. J Cardiothorac Vasc Anesth 2013; 27:e77-8. [DOI: 10.1053/j.jvca.2013.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Indexed: 11/11/2022]
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18
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Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
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Tehrani S, Malik A, Hausenloy DJ. Cardiogenic Shock and the ICU Patient. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cardiogenic shock is one of the most important complications of acute myocardial infarction (MI) and acute left ventricular failure (LVF). It threatens the life of 5–10% of patients with ST-segment elevation myocardial infarction (STEMI) particularly in the presence of inappropriately low peripheral vascular resistance. Cardiogenic shock results in poor tissue perfusion, end-organ damage and carries a high mortality risk. The goal of therapy is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial blood pressure, which is achieved with the use of inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption and extended myocardial ischaemia. Current therapeutic approaches include early coronary artery revascularisation (which has significantly improved the survival rate), fluid resuscitation, inotropic support and mechanical circulatory support using intra-aortic balloon pumps or ventricular assist devices. In this article, we review the pathophysiology, diagnosis and management of cardiogenic shock.
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Affiliation(s)
- Shana Tehrani
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
| | - Abdul Malik
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
| | - Derek J Hausenloy
- Reader in Cardiovascular Medicine
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Medicine, University College London
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Hou ZQ, Sun ZX, Su CY, Tan H, Zhong X, Hu B, Zhou Y, Shang DY. Effect of Levosimendan on Estimated Glomerular Filtration Rate in Hospitalized Patients with Decompensated Heart Failure and Renal Dysfunction. Cardiovasc Ther 2013; 31:108-14. [PMID: 23490237 DOI: 10.1111/1755-5922.12001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Zhi-Qiang Hou
- Emergency Department; Shandong Provincial Hospital Affiliated to Shandong University; Jinan; China
| | - Zhao-Xia Sun
- Department of Cardiology; 2nd People's Hospital of Jinan; Jinan; China
| | - Chong-Yi Su
- Emergency Department; Shandong Provincial Hospital Affiliated to Shandong University; Jinan; China
| | - Hui Tan
- Emergency Department; Shandong Provincial Hospital Affiliated to Shandong University; Jinan; China
| | - Xia Zhong
- Emergency Department; Shandong Provincial Hospital Affiliated to Shandong University; Jinan; China
| | - Bo Hu
- Emergency Department; Shandong Provincial Hospital Affiliated to Shandong University; Jinan; China
| | - Yi Zhou
- Emergency Department; Shandong Provincial Hospital Affiliated to Shandong University; Jinan; China
| | - De-Ya Shang
- Emergency Department; Shandong Provincial Hospital Affiliated to Shandong University; Jinan; China
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21
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Ogawa R, Stachnik JM, Echizen H. Clinical Pharmacokinetics of Drugs in Patients with Heart Failure. Clin Pharmacokinet 2013; 52:169-85. [DOI: 10.1007/s40262-012-0029-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rafouli-Stergiou P, Parissis JT, Anastasiou-Nana M. Inotropes for the management of acute heart failure patients with renal dysfunction. Still an option? Expert Opin Pharmacother 2012; 13:2637-47. [PMID: 23170968 DOI: 10.1517/14656566.2012.749859] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Renal dysfunction is highly prevalent in patients with acute heart failure (AHF). These patients are more vulnerable in worsening of kidney function and have also higher mortality rates. AREAS COVERED Recent developments in the understanding of bidirectional interaction between heart and kidney are reviewed in the context of the potential impact of inotropes on renal function. Key clinical trials reporting the use of inotropes in AHF patients with renal dysfunction are discussed in this review. EXPERT OPINION Inotropes may be indicated on a short-term basis and under close monitoring in AHF with renal dysfunction mostly in cases of low output heart failure that can provoke renal hypoperfusion. Dopamine administration with low dose of i.v. furosemide has been recently compared with high dose of i.v. furosemide alone, demonstrating lower rates of worsening renal function and electrolyte disturbances. Moreover, small clinical trials have shown that the novel inodilator levosimendan seems to be superior to dobutamine or placebo in improving renal function in patients with acutely decompensated heart failure. The impact of novel inotropes on kidney function is still unclear. Randomized clinical trials are required in order to identify the role of inotropes in the management and/or prevention of acute cardiorenal syndrome.
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Ristikankare A, Pöyhiä R, Eriksson H, Valtonen M, Leino K, Salmenperä M. Effects of Levosimendan on Renal Function in Patients Undergoing Coronary Artery Surgery. J Cardiothorac Vasc Anesth 2012; 26:591-5. [DOI: 10.1053/j.jvca.2012.01.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Indexed: 11/11/2022]
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Toller W, Algotsson L, Guarracino F, Hörmann C, Knotzer J, Lehmann A, Rajek A, Salmenperä M, Schirmer U, Tritapepe L, Weis F, Landoni G. Perioperative use of levosimendan: best practice in operative settings. J Cardiothorac Vasc Anesth 2012; 27:361-6. [PMID: 22658687 DOI: 10.1053/j.jvca.2012.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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25
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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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Davenport A, Anker SD, Mebazaa A, Palazzuoli A, Vescovo G, Bellomo R, Ponikowski P, Anand I, Aspromonte N, Bagshaw S, Berl T, Bobek I, Cruz DN, Daliento L, Haapio M, Hillege H, House A, Katz N, Maisel A, Mankad S, McCullough P, Ronco F, Shaw A, Sheinfeld G, Soni S, Zamperetti N, Zanco P, Ronco C. ADQI 7: the clinical management of the Cardio-Renal syndromes: work group statements from the 7th ADQI consensus conference. Nephrol Dial Transplant 2010; 25:2077-2089. [DOI: 10.1093/ndt/gfq252] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Follath F. Newer treatments for decompensated heart failure: focus on levosimendan. DRUG DESIGN DEVELOPMENT AND THERAPY 2009; 3:73-8. [PMID: 19920923 PMCID: PMC2769227 DOI: 10.2147/dddt.s3097] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Acute heart failure (AHF) is a major cause of hospitalizations. Severe dyspnea, pulmonary congestion and low cardiac output with peripheral vasoconstriction and renal hypoperfusion is a main form of clinical presentation. Most patients with acute worsening have a pre-existing decompensated chronic heart failure (ADCHF), but AHF may also occur as a first manifestation of a previously unknown heart disease. Myocardial ischemia, cardiac arrhythmias, non-compliance with medication and infections are frequent precipitating factors. Management of AHF depends on the underlying heart disease and cause of decompensation. In patients with ADCHF vasodilators and iv diuretics are first-line drugs for rapid reduction of dyspnea and congestion. In patients with signs of low cardiac output and oliguria, inotropic agents are also often administered to prevent further deterioration. Beta-adrenergic agents and phosphodiesterase inhibitors correct the hemodynamic disturbance, but may also induce arrhythmias and worsen myocardial ischemia. Inotropic therapy therefore remains controversial. A novel class of drugs, the calcium sensitizers, represent a new therapeutic option. Levosimendan was shown to improve myocardial contractility without increasing oxygen requirements and to produce peripheral and coronary vasodilation. Its therapeutic effects and tolerance have been tested in several trials. The present review focuses on the clinical pharmacology and therapeutic utility of levosimendan in patients with ADCHF.
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Affiliation(s)
- Ferenc Follath
- Steering Group Drug Therapy, University Hospital Zürich, Raemistrasse 100, Zürich, Switzerland.
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28
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Makita T, Aiba T, Izuwa Y, Komori Y, Kawasaki H, Kurosaki Y. Efficacy of peritoneal dialysis of tolbutamide in rats under conditions of the plasma unbound fraction being increased. Biopharm Drug Dispos 2009; 30:1-8. [DOI: 10.1002/bdd.640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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29
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Rehberg S, Enkhbaatar P, Traber DL. Role of the Calcium Sensitizer, Levosimendan, in Perioperative Intensive Care Medicine. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_47] [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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30
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31
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Current World Literature. Curr Opin Anaesthesiol 2008; 21:85-8. [DOI: 10.1097/aco.0b013e3282f5415f] [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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32
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Puttonen J, Laine T, Ramela M, Häkkinen S, Zhang W, Pradhan R, Pentikäinen P, Koskinen M. Pharmacokinetics and excretion balance of OR-1896, a pharmacologically active metabolite of levosimendan, in healthy men. Eur J Pharm Sci 2007; 32:271-7. [PMID: 17888637 DOI: 10.1016/j.ejps.2007.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Revised: 08/03/2007] [Accepted: 08/04/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the pharmacokinetics and excretion balance of [(14)C]-OR-1896, a pharmacologically active metabolite of levosimendan, in six healthy male subjects. In addition, pharmacokinetic parameters of total radiocarbon and the deacetylated congener, OR-1855, were determined. METHODS OR-1896 was administered as a single intravenous infusion of 200 microg of [(14)C]-OR-1896 (specific activity 8.6 MBq/mg) over 10 min. The pharmacokinetic parameters were calculated by three-compartmental methods. RESULTS During the 14-day collection of urine and faeces, excretion (+/-S.D.) averaged 94.2+/-1.4% of the [(14)C]-OR-1896 dose. Mean recovery of radiocarbon in urine was 86.8+/-1.9% and in faeces 7.4+/-1.5%. Mean terminal elimination half-life of OR-1896 (t(1/2)) was 70.0+/-44.9 h. Maximum concentrations of OR-1855 were approximately 30% to that of OR-1896. Total clearance and the volume of distribution of OR-1896 were 2.0+/-0.4 l/h and 175.6+/-74.5l, respectively. Renal clearances of OR-1896 and OR-1855 were 0.9+/-0.4 l/h and (5.4+/-2.3)x10(-4) l/h, respectively. CONCLUSIONS This study provides data to demonstrate that nearly one half of OR-1896 is eliminated unchanged into urine and that the active metabolites metabolite of levosimendan remain in the body longer than levosimendan. The remaining half of OR-1896 dose is eliminated through other metabolic routes, partially through interconversion back to OR-1855 with further metabolism of OR-1855. Given the fact that the pharmacological activity and potency of OR-1896 is similar to levosimendan, these results emphasize the clinical significance of OR-1896 and its contribution to the long-lasting effects of levosimendan.
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Affiliation(s)
- Jaakko Puttonen
- Research and Development, Orion Pharma, P.O. Box 1780, FIN-70701 Kuopio, Finland.
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Yilmaz MB, Yalta K, Yontar C, Karadas F, Erdem A, Turgut OO, Yilmaz A, Tandogan I. Levosimendan Improves Renal Function in Patients with Acute Decompensated Heart Failure: Comparison with Dobutamine. Cardiovasc Drugs Ther 2007; 21:431-5. [DOI: 10.1007/s10557-007-6066-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Accepted: 10/08/2007] [Indexed: 11/28/2022]
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Abstract
Levosimendan has been developed for the treatment of decompensated heart failure and is used intravenously when patients with heart failure require immediate initiation of drug therapy. It increases cardiac contractility and induces vasodilatation. The pharmacokinetics of levosimendan are linear at the therapeutic dose range of 0.05-0.2 microg/kg/minute. The short half-life (about 1 hour) of the parent drug, levosimendan, enables fast onset of drug action, although the effects are long-lasting due to the active metabolite OR-1896, which has an elimination half-life of 70-80 hours in patients with heart failure (New York Heart Association functional class III-IV). Although levosimendan is administered intravenously, it is excreted into the small intestine and reduced by intestinal bacteria to an amino phenolpyridazinone metabolite (OR-1855). This metabolite is further metabolised by acetylation to N-acetylated conjugate (OR-1896). The circulating metabolites OR-1855 and OR-1896 are formed slowly, and their maximum concentrations are seen on average 2 days after stopping a 24-hour infusion. The haemodynamic effects after levosimendan seem to be similar between fast and slow acetylators despite the fact that the enzyme N-acetyltransferase-2, which is responsible for the metabolism of OR-1855 to OR-1896, is polymorphically distributed in the population. Levosimendan reduces peripheral vascular resistance and has direct contractility-enhancing effects on the failing left ventricle. It also improves indices of diastolic function and seems to improve the function of stunned myocardium. Despite an improvement in ventricular function, levosimendan does not increase myocardial oxygen uptake significantly. An increase in coronary blood flow and a reduction in coronary vascular resistance have been observed. Levosimendan reduces plasma brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) levels substantially, and a decrease in plasma endothelin-1 has been observed. Levosimendan also exerts beneficial effects on proinflammatory cytokines and apoptosis mediators. The effects of a 24-hour levosimendan infusion on filling pressure, ventricular function and BNP, as well as NT-proBNP, last for at least 7 days.
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Affiliation(s)
- Saila Antila
- National Agency for Medicines, Helsinki, Finland.
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