title: The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion.
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.
authors.affiliation: Helsinki University Central Hospital, Helsinki, Finland. Electronic address: markku.nieminen@hus.fi.
authors.forename: Markku S
authors.initials: MS
authors.lastname: Nieminen
authors.affiliation: Department of Internal Medicine II, St. Marien Hospital Siegen, Siegen, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Buerke
authors.affiliation: Department of Cardiology, Lariboisière Hospital, Paris, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Cohen-Solál
authors.affiliation: Department of Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal.
authors.forename: Susana
authors.initials: S
authors.lastname: Costa
authors.affiliation: Department of Cardiology, University of Debrecen, Debrecen, Hungary.
authors.forename: István
authors.initials: I
authors.lastname: Édes
authors.affiliation: Laboratory of Clinical Cardiology, Scientific Research Institute of Physical-Chemical Medicine, Moscow, Russia.
authors.forename: Alexey
authors.initials: A
authors.lastname: Erlikh
authors.affiliation: Department of Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal.
authors.forename: Fatima
authors.initials: F
authors.lastname: Franco
authors.affiliation: Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
authors.forename: Charles
authors.initials: C
authors.lastname: Gibson
authors.affiliation: Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia.
authors.forename: Vojka
authors.initials: V
authors.lastname: Gorjup
authors.affiliation: Department of Cardiothoracic Anesthesia and Intensive Care, University Hospital of Pisa, Pisa, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Guarracino
authors.affiliation: Heart Center, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Finn
authors.initials: F
authors.lastname: Gustafsson
authors.affiliation: Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.
authors.forename: Veli-Pekka
authors.initials: VP
authors.lastname: Harjola
authors.affiliation: Department of Cardiology, Oslo University Hospital, Oslo, Norway.
authors.forename: Trygve
authors.initials: T
authors.lastname: Husebye
authors.affiliation: Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
authors.forename: Kristjan
authors.initials: K
authors.lastname: Karason
authors.affiliation: Cardiological Intensive Care Unit, Alexandrovski Central Clinical Hospital, Kiev, Ukraine.
authors.forename: Igor
authors.initials: I
authors.lastname: Katsytadze
authors.affiliation: Department of Intensive Care and Respiratory Medicine, The Royal Brompton & Harefield Hospitals NHS Trust, London, UK.
authors.forename: Sundeep
authors.initials: S
authors.lastname: Kaul
authors.affiliation: Critical Care Proprietary Products, Orion Pharma, Espoo, Finland.
authors.forename: Matti
authors.initials: M
authors.lastname: Kivikko
authors.affiliation: Cardiological Intensive Care Unit, Cardiological Center Monzino, Milan, Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Marenzi
authors.affiliation: Department of Intensive Care Medicine, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain.
authors.forename: Josep
authors.initials: J
authors.lastname: Masip
authors.affiliation: Department of Cardiology, University Clinic, Lomonosov Moscow State University, Moscow, Russia.
authors.forename: Simon
authors.initials: S
authors.lastname: Matskeplishvili
authors.affiliation: Department of Anaesthesia and Burn and Critical Care, Saint-Louis-Lariboisière Hospital, AP-HP, University Paris-Diderot, Paris, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mebazaa
authors.affiliation: Department of Cardiology, Odense University Hospital, Denmark.
authors.forename: Jacob E
authors.initials: JE
authors.lastname: Møller
authors.affiliation: Jagiellonian University Medical College, Faculty of Medicine, Institute of Cardiology, Department of Coronary Heart Disease and Heart Failure, John Paul II Hospital, Cracow, Poland.
authors.forename: Jadwiga
authors.initials: J
authors.lastname: Nessler
authors.affiliation: 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.
authors.forename: Bohdan
authors.initials: B
authors.lastname: Nessler
authors.affiliation: Department of Cardiology, Alexandra General Hospital of Athens, Athens, Greece.
authors.forename: Argyrios
authors.initials: A
authors.lastname: Ntalianis
authors.affiliation: Department of Cardiology II, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Oliva
authors.affiliation: Department of Internal Medicine IV, Hietzing Hospital, Vienna, Austria.
authors.forename: Emel
authors.initials: E
authors.lastname: Pichler-Cetin
authors.affiliation: Department of Cardiology, North Estonia Medical Center, Tallinn, Estonia.
authors.forename: Pentti
authors.initials: P
authors.lastname: Põder
authors.affiliation: Department of Cardiology, University Hospital Virgen Macarena, Seville, Spain.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Recio-Mayoral
authors.affiliation: Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.
authors.forename: Steffen
authors.initials: S
authors.lastname: Rex
authors.affiliation: Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University Prague, Czech Republic.
authors.forename: Richard
authors.initials: R
authors.lastname: Rokyta
authors.affiliation: University of Dresden, Heart Center Dresden, University Hospital, Dresden, Germany.
authors.forename: Ruth H
authors.initials: RH
authors.lastname: Strasser
authors.affiliation: Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
authors.forename: Endre
authors.initials: E
authors.lastname: Zima
authors.affiliation: Critical Care Proprietary Products, Orion Pharma, Espoo, Finland.
authors.forename: Piero
authors.initials: P
authors.lastname: Pollesello
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000188:drug therapy*; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D004357:Drug Synergism; D006333:Heart Failure / Q000188:drug therapy* / Q000209:etiology; D006801:Humans; D006835:Hydrazones / Q000627:therapeutic use*; D011379:Prognosis; D011724:Pyridazines / Q000627:therapeutic use*; D000077464:Simendan
chemical_list: D000889:Anti-Arrhythmia Agents; D006835:Hydrazones; D011724:Pyridazines; D000077464:Simendan
keywords: Acute coronary syndrome; Cardiogenic shock; Heart failure; Levosimendan