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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 December 2018

December 2018 post

Levosimendan Ends 2018 on a High Note

Earlier this year (May 27-28), the Heart Failure 2018 congress of the European Society of Cardiology-Heart Failure Association convened in Vienna, Austria.  A series of tutorials delivered by experts from nine European countries examined how to use levosimendan safely and effectively in acute and advanced heart failure, including in the context of renal dysfunction.

Contributors to that lecture series have now distilled into print their experience and views on the position of levosimendan in the management of acute and advanced heart failure in a review published in Cardiovascular Drugs and Therapy (Bouchez S et al. 2018 Nov 6. doi: 10.1007/s10557-018-6838-2. [Epub ahead of print]). It seems fitting that we should conclude our monthly blog posts for 2018 with a brief summary of this excellent tour d’horizon from a group of notable and respected practitioners in this complex field.

A series of major points emerged from this review.

(1)  Meta-analyses of levosimendan data in various settings, including AHF and AdHF, indicated a trend towards a survival benefit that reached statistical significance in some investigations, though not all. Of note, however, none of these meta-analyses produced any indication that the use of levosimendan is associated with an increase of mortality, whereas a worsening impact on survival has been reported for other inotropes or inodilators.

(2)  In advanced heart failure meta-analysis indicates a clear and consistent effect of levosimendan to reduce re-hospitalizations. Given that patients with AdHF may comprise up to 10% of the overall heart failure population these benefits may be accessible to substantial numbers of patients.

(3)  Bouchez and colleagues re-iterate the advice of the authors of the 2016 ESC guidelines on acute and chronic heart failure, who recommend use of levosimendan in cases where there is concomitant use of beta-blockers.

(4)  Levosimendan both in the acute setting and in the repetitive/intermittent context of AdHF appears to a promising option to improve renal perfusion or to reverse or ameliorate renal dysfunction but further controlled trials are needed to confirm the status of levosimendan for this purpose. In particular, they emphasize the conclusions of Lannemyr et al. who recently suggested that levosimendan “could be the preferred inotropic agent for treatment of the cardiorenal syndrome”. (J Am Heart Assoc. 2018;7: e008455. doi: 10.1161/JAHA.117.008455.)

These are substantial attainments for any drug in these areas of heart failure therapy and they confirm levosimendan as a uniquely-configured resource for this field. Join us again in 2019 for the next chapters in the development of this remarkable agent.

 

 

 

7 November 2018

November 2018 post

The price of the drug is only part of the cost of treatment

Among cardiovascular diseases, heart failure (HF) is often referred to as a ‘final-stage’ condition. The prognosis is poor, with a mortality rate of approximately 50% within the first 5 years following diagnosis [Liao L et al. Economic burden of heart failure in the elderly. Pharmacoeconomics. 2008;26:447–62].

Patients with advanced HF (AdHF) are a relatively small but important contingent of the wider HF population who face substantial morbidity through continued deterioration of symptoms, and frequent hospitalization. AdHF places a considerable economic burden on hospital budgets, and therapies aimed at reducing the re-hospitalization rate have the potential to be of great economic value.

A useful contribution on this theme appeared earlier this year in the form of an abstract presented at the 2018 World Congress on Acute Heart Failure [Eur J Heart Fail. 2018;20 (Suppl. S1):398]. Prepared by Dr Josep Comin-Colet of the Bellvitge Hospital, Barcelona, Spain and fellow LION-HEART investigators, plus Spanish experts in health economics and outcomes research, this work reported on the net cost of intermittent intravenous levosimendan, given as an outpatient treatment to patients with AdHF.

Levosimendan therapy in the LION-HEART RCT reduced the rate of hospitalization for HF from the 66.7% seen in the control group to 22.9%. Hospitalizations for worsening HF are expensive: averting them saves money as well as improving patients’ quality of life. In the case of the Spanish centres enrolled in LION-HEART, the per-patient saving realized by using intermittent levosimendan was €2978.16. By including costs of the medications and other costs, therefore, use of intermittent levosimendan saved over €1000 per patient, net.  A probabilistic analysis suggested a 94% chance of a saving.

The lesson from this research—and it’s not the first time such a lesson has emerged from pharmaco-economic analyses of levosimendan—is that the price of the drug is only part of the cost of treatment and that interventions that avert HF-related hospitalizations can in fact be much more affordable than a narrow focus on the unit price might suggest. Such outcomes are also of significant benefit to many patients and we should never lose sight of that.

19 October 2018

October 2018 post

Greetings from expert meeting in Athens

An expert meeting organized by the Heart Failure Clinic, Attikon University Hospital, was held in Athens on Sept 27-28 on the theme “Inotropes for the management of acute and advanced heart failure: practical considerations, tips and tricks, future directions”.

Thirty-five experts from 21 European countries ranging geographically from Finland and Russia via Turkey and Israel to Cyprus and Spain grappled with the live issues of the field, including the definitions of acute and advanced heart failure, the need for haemodynamic, neurohormonal and symptom stabilization, the ambition for (and sometimes tension between) quality and quantity of life, the uses of inotropes and their effects on the heart, lungs, kidney, and other organs in those settings. A consensus publication on the practical use of inotropes in those settings is planned for Q1 2019, with special focus on levosimendan.

This meeting represents the continuation of an initiative developed during the past decade and intended to promote clinical awareness of levosimendan while ensuring that the science and clinical experience underpinning the drug’s status in the cardiology repertoire is subject to regular updating and rigorous scrutiny through consensus development and peer review [1-7]. Having participated in several of these meetings I can attest to the calibre of the faculties involved, the depth and breadth of the discussions and the even-handed way that data is analysed and conclusions are reached. These meetings are not just a chance to catch up with colleagues in an agreeable location: there is a commitment to reaching and publishing serious reflections on best practice. Here are some examples from previous meetings held under the same auspices, all of which reward the effort of reading.

  1. Nieminen MS et al. The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion. Int J Cardiol. 2016;218:150-157.
  2. Nieminen MS et al. The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations. Int J Cardiol. 2015;191:256-64
  3. Nieminen MS et al. Repetitive use of levosimendan for treatment of chronic advanced heart failure: clinical evidence, practical considerations, and perspectives: an expert panel consensus. Int J Cardiol. 2014;174(2):360-7.
  4. Yilmaz MB et al. Renal effects of levosimendan: a consensus report. Cardiovasc Drugs Ther. 2013;27(6):581-90.
  5. Pölzl G et al. Repetitive use of levosimendan in advanced heart failure: need for stronger evidence in a field in dire need of a useful therapy. Int J Cardiol. 2012;159:82-7.
  6. Farmakis D et al. Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper. Int J Cardiol. 2016;222:303-312
  7. Altenberger J et al. Levosimendan in Acute and Advanced Heart Failure: An Appraisal of the Clinical Database and Evaluation of Its Therapeutic Applications. J Cardiovasc Pharmacol. 2018;71(3):129-136