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June 2018 post

6/7/2018 8:00:00 AM

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.