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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

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

5 April 2018

April 2018 post

What does the Advanced Heart Failure patient want?

In the preamble to their recent paper “Development and testing of a goals of care intervention in advanced heart failure” [Appl Nurs Res. 2017;38:99-106] Professor Cynthia M Dougherty and colleagues outline an array of options for the treatment of advanced heart failure (HF) that create – quite reasonably – the impression that we are in a golden age of therapeutic possibilities for this difficult condition: recurrent parenteral infusions, implanted ventricular assist devices and cardioverter defibrillators, cardiac transplantation, and the total artificial heart.

 

But is a life dominated by this panoply of interventions in every case what our patients want? Maybe; maybe not: and very likely not the same answer every time. We have a responsibility to identify their goals.

 

Dougherty and colleagues’ article is a contribution to the expanding science of “goals of care (GoC)”. I am not going to do them the discourtesy of trying to summarize a complex and supple piece of research in this short blog beyond revealing that giving patients’ the skills and confidence to initiate and maintain constructive conversations about what they want from their treatment emerges as a vital aspect of excellence in medical care for advanced heart failure.

 

In the authors’ own words “Holding a GoC conversation between patient and provider is expected to facilitate concordance between care received and the patient’s values and goals, assist in shared decision making about possible new HF therapies, improve patient-provider communication, and potentially improve quality of life.” We have to note that “is expected”: the outcome we aspire to may not be fully achieved in every case. But to aspire to those outcomes is from every point of view absolutely the right thing to do and I would urge all those involved in the care of patients with advanced heart failure to make a careful study of research on GoC (below are some other recent leads to get you started) and to bring well-founded understanding of patient goals and wishes into the heart of their practice.

 

Leads

• An Intervention to Enhance Goals-of-Care Communication Between Heart Failure Patients and Heart Failure Providers.[J Pain Symptom Manage. 2016]

• Does an intervention designed to improve self-management, social support and awareness of palliative-care address needs of persons with heart failure, family caregivers and clinicians?[J Clin Nurs. 2018]

• Feasibility and acceptability of a nursing intervention with family caregiver on self-care among heart failure patients: a randomized pilot trial.[Pilot Feasibility Stud. 2016]