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Acute and Advanced Heart Failure Blog

Professor Gerhard Pölzl is Chief of the Heart Failure and Heart Transplant Program at the Medical University Innsbruck. His research is focused on clinical studies in advanced and chronic heart failure and on translational studies in cardiomyopathies.

He has been Principal Investigator of the LevoRep clinical trial that tested the efficacy and safety of pulsed infusions of levosimendan in outpatients with advanced heart failure. He is now P.I. of the clinical trial LEODOR, on repetitive use of levosimendan in advanced heart failure.

This blog is focused on the therapeutic options for Acute and Advanced Heart Failure: new data, new studies, new opinions, new trends.


Latest posts

3 August 2018

August 2018 post

The summer holiday season is in full swing and I hope yours is going well.

Science and medicine never entirely stop, however, and many of us will spend at least a little time in the coming weeks devising our schedules for the 2018 congress of the European Society of Cardiology, which convenes this year in Munich, Germany from Saturday 25 August to Wednesday 29 August.

In amongst the main schedule of the congress is a series of very attractive symposia supported by Orion Pharma that I take this opportunity to draw to your attention.

You can get full particulars of the programme here. The aspects that draw my particular attention are:

(1) this is a lecture series with an unashamedly practical emphasis that addresses the major questions in the management of patients with acute or advanced heart failure

(2) this advice is offered by a faculty every member of which is an acknowledged and respected practitioner in this area of cardiology whose experience in these often difficult cases has been acquired at the bedside and at first-hand. They know what they are talking about.

So, if you are planning to attend ESC 2018 block out some time in your congress programme book or your congress programme app and come to some of these tutorials: they’re concise, they’re lively and they’re packed with information. The whole programme repeats from Sunday to Tuesday, so there’s ample opportunity for you to fit in the whole series, plus there’s a promise of light refreshments that may be especially welcome if Europe’s summer heat-wave lasts to the end of August!

7 June 2018

June 2018 post

Another Uptick for Levosimendan in Advanced Heart Failure

 

When the Heart Failure Association of the European Society of Cardiology (HFA-ESC) issues a fresh position paper on the identification and management of advanced heart failure this blog has a duty to pay attention. Well, the HFA-ESC has issued a fresh position paper [Crespo-Leiro MG et al. Eur J Heart Fail. 2018 May 27. doi: 10.1002/ejhf.1236] and here’s our first take on some highlights.

(1) A new definition of advanced heart failure

The Association offers a new definition that reflects the altered medical and scientific landscape of the past decade. Technically, this new definition rests on 4 clinical criteriaall of which must be present despite optimal guideline-directed treatment but its philosophy is found in the advice that “[Diagnosis of] advanced heart failure does not depend on ejection fraction, but on the patient’s symptoms, prognostic markers, presence of end-organ damage, and goals for therapy.”

It’s worth also noting that the HFA-ESC regards unplanned outpatient visits for worsening symptoms of heart failure as a significant sign and gives such visits the same diagnostic value as a heart failure-related hospitalization. This is consistent with its stance that advancing heart failure represents “a decompensated and unstable state in which standard treatment is, by definition, insufficient”.

(2) Recognition for levosimendan

Levosimendan emerges quite strongly from the new HFA-ESC position paper: it’s worth quoting verbatim some key statements:

(1) Intermittent use of inodilators for long-term symptomatic improvement or palliation has gained popularity, especially use of levosimendan, since the hemodynamic effects may last for >7 days after a 12–24 h infusion because of the pharmacologically active metabolite with a long half-life.

(2) Meta-analyses of several heterogeneous small trials of a [levosimendan] repeated infusion strategy have suggested a positive effect on survival and a reduction in hospitalizations.

(3) In the LION-HEART pilot study patients randomized to levosimendan were…less likely to be hospitalized for heart failure or experience a decline in health-related quality of life compared to placebo. Adverse events were similar between groups.

Medication can only be short-term response to the challenge of advanced heart failure but these notes from the HFA-ESC indicate that within that remit levosimendan is moving into the mainstream and may be considered as a bridge strategy to sustain a patient until mechanical circulatory support or a heart transplant can be provided.

8 May 2018

May 2018 post

Levosimendan in Cardiac Surgery: The Evidence Adds Up

 

If we had a way to reduce the risk of life-threatening complications after cardiac surgery would we use it?  Of course we would. It is for reason that this month’s blog post highlights the recent work of Dr. Qiang and colleagues [1]. In the most up-to-date and comprehensive research of its kind these researchers identified and analyzed data from 25 randomized controlled trials (RCTs) that compared perioperative use of levosimendan with control (placebo, conventional inotropes or intra-aortic balloon pump) in 3247 adult cardiac surgery patients and reported an impressive array of benefits. The main results are that

 

1. Levosimendan reduced mortality after cardiac surgery (OR 0.63; P=0.001). This survival benefit was not confined to patients with markedly reduced left ventricular ejection fraction (LVRF): it extended to patients with LVEF up to 50%. So even patients with only moderate depression of LVEF gained from levosimendan treatment.

 

2. Levosimendan use also significantly reduced: the incidence of postoperative acute kidney injury (OR 0.55; P<0.0001), the use of renal replacement therapy use (OR 0.56; P=0.002), the duration of ICU stay (weighted mean difference [WMD] -0.49 day; P=0.0002), and the duration of mechanical ventilation (WMD -2.30 h; P=0.002).

 

Data of this sort make a strong case for the peri-operative use of levosimendan in adult cardiac surgery but they can’t answer every question. In particular, the outcomes of some recent randomized trials [2,3,4] points to the need for further work to define the optimal dose-range: Qiang and colleagues [1] suggest that adult cardiac surgery may be a situation where initial bolus dosing and a relatively high infusion rate may be needed to secure the full clinical benefit of levosimendan unique inodilator actions. If that proves indeed to be the case then the well-documented safety profile of levosimendan will by another feature favoring its use.

 

References:

1. Qiang H et al. J Cardiovasc Pharmacol 2018 Publish Ahead of Print Apr 3. PMID: 29672418, DOI: 10.1097/FJC.0000000000000584
2. Landoni G et al. N Engl J Med. 2017;376(21):2021-2031
3. Mahta RH et al. N Engl J Med. 2017;376(21):2032-2042
4. Cholley B et al. JAMA. 2017;318(6):548-556