An update on levosimendan in acute cardiac care: applications and recommendations for optimal efficacy and safety

Abstract

Introduction: In the 20 years since its introduction to the palette of intravenous hemodynamic therapies, the inodilator levosimendan has established itself as a valuable asset for the management of acute decompensated heart failure. Its pharmacology is notable for delivering inotropy via calcium sensitization without an increase in myocardial oxygen consumption. Areas covered: Experience with levosimendan has led to its applications expanding into perioperative hemodynamic support and various critical care settings, as well as an array of situations associated with acutely decompensated heart failure, such as right ventricular failure, cardiogenic shock with multiorgan dysfunction, and cardio-renal syndrome. Evidence suggests that levosimendan may be preferable to milrinone for patients in cardiogenic shock after cardiac surgery or for weaning from extracorporeal life support and may be superior to dobutamine in terms of short-term survival, especially in patients on beta-blockers. Positive effects on kidney function have been noted, further differentiating levosimendan from catecholamines and phosphodiesterase inhibitors. Expert opinion:Levosimendan can be a valuable resource in the treatment of acute cardiac dysfunction, especially in the presence of beta-blockers or ischemic cardiomyopathy. When attention is given to avoiding or correcting hypovolemia and hypokalemia, an early use of the drug in the treatment algorithm is preferred.

Levosimendan in intensive care and emergency medicine: literature update and expert recommendations for optimal efficacy and safety

“…Beyond its principal indication in the management of acutely decompensated chronic heart failure (AHF), levosimendan has been evaluated for its potential in a range of emergency and critical care applications, including postoperative (predominantly cardiac surgery) situations, sepsis/septic shock, renal impairment/failure and cardiogenic shock (CS). Previous reviews and expert opinion articles have summarized the clinical experience in those areas and provided recommendations for practice [2][3][4][5].…”

“…levosimendan only. d) Focus on eight therapeutic settings of intensive care unit (ICU) and emergency medicine (EM), excluding hospitalization for AHF or advanced heart failure (because described in a separate update [3]). The selected areas are (1) postoperative settings, (2) septic shock, (3) weaning from ventilator, (4) weaning from veno-arterial extracorporeal membrane oxygenation (VA-ECMO), ( 5) cardiogenic shock, (6) Takotsubo syndrome (TTS), (7) acute cardiac care complicated by renal dysfunction/failure, and (8) pulmonary hypertension (PH) and right ventricular dysfunction.…”

Evidence and Current Use of Levosimendan in the Treatment of Heart Failure: Filling the Gap

“…Its predictable safety profile requires to appropriately manage hypovolemia and hypokalemia to reduce the risk of arrhythmias and hypotension. 82 …”

“…Its predictable safety profile requires to appropriately manage hypovolemia and hypokalemia to reduce the risk of arrhythmias and hypotension. 82 After its first approval over 20 years ago levosimendan underwent a profound and diverse development that have brought the drug from the management of acute HF in ICUs to the treatment of chronic heart insufficiency in ambulatory setting, with additional emerging evidence in the neuromuscular disease area such as ALS. Most of this development has been linked to investigator-driven studies, which did not lead to any significant change of the original 20y-old label of the drug.…”

Levosimendan in Europe and China: An Appraisal of Evidence and Context

“…For similar reasons, in this review we did not touch the perioperative use of the drug or its use in intensive care unit settings. [ 72 , 73 ] Instead, we focused on its main indications in acute heart failure and acute cardiac care, as recently defined in the reviews by Farmakis et al and Heringlake et al[ 74 , 75 ]…”