The inodilator levosimendan as a treatment for acute heart failure in various settings

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.

Keywords: Acute coronary syndromes; Cardiogenic shock; Inodilator; Left ventricular assist device; Levosimendan; Pulmonary hypertension.

Figure 1

Derivation of arterial elastance (Ea) and ventricular elastance (Ees) for the assessment of ventriculo-arterial coupling efficiency. The pressure–volume loop area is shaded. The slopes of Ees and Ea are shown. See text for further discussion. LVESV, left ventricular end-systolic volume; LVESP, left ventricular end-systolic pressure; LVEDV, left ventricular end-diastolic volume; LVEDP, left ventricular end-diastolic pressure; LV, left ventricular; SV, stroke volume; V0, theoretical volume when no pressure is generated. Reproduced with permission from Guarracino et al.

Figure 2

The GFR response to inodilatation may be used to guide a patient’s eligibility for a place on the heart transplant register. HTX, heart transplantation; ACE-I, angiotensin-converting enzyme inhibitor; GFR, glomerular filtration rate; BB, beta-blockers; BP, blood pressure; sys, systolic.