Importance of levosimendan in the management of cardiogenic shocks

M DRIDI1,2, F JENANE3, MA YOUSFI3, I LABBEN4, A JBALI4, A LEBBI4, C RHOMDANI4, A JANDOUBI4, M FERDJANI4. 1Faculty of Pharmacy Monastir, Pharmacology, Tunisia, 2General Direction of Military Health, Central Pharmacy, Tunisia, 3Military Hospital of Tunis, Pharmacy, Tunisia, 4Military Hospital of Tunis, Anesthesiology Reanimation, Tunisia

Levosimendan is a new sensitizer of contractile proteins to calcium through the opening of ATP-dependent potassium channels witch leads to better myocardial contractility, vasodilatation and protective effect.

Through this retrospective study, the authors tried to assess the death rate due to cardiogenic shocks and the importance of levosimendan for decreasing this mortality.

This retrospective study was carried out in our department and involved all cases of acute myocardial failure that required the administration of levosemendan during 3 years (January 2009- December 2011).

Statistic analysis was done using SPSS software version 15.0. Results were given in averages ± standard deviation in addition to extremes. Chi-squared test was used for determining the qualitative variables and student’s test for the qualitative variables. The significance threshold was 5%.

Thirty five patients (24 men and 11 women; sex-ration 2.18) aged 55 years on average (±20) (range 17- 82 years) were included in our study. Levosimendan was prescribed in the following cases of low cardiac output: post myocardial infarction left ventricular failure (29.7% of cases), septic cardiogenic shock (16.2% of cases), after cardiac surgery (8.1%) and decompensate heart failure (46% of cases).

Analysis of hemodynamic values showed that on admission, the heart rate was significantly more important in the groups of deceased patients compared with the group of surviving ones (117±14 vs 95±16 bpm; p= 0.002) and that the diastolic blood pressure was significantly lower in the group of deceased patients (50 ±9 vs 61±13 mmHg; p= 0.017). As for laboratory studies on admission, they were as follows: mean lactate values were 3.2±2.6 mmol/l), troponins 7.6±24 µmol/l, mean CRP value 134±92 mg/l and mean blood creatine level 269±190 µmol. Twelve patients (34%) were undergoing hemofiltration. Predicted global mortality (PM) indicated by the mean simplified severity index (SSI) calculated on admission was 43.6±28.2%. In our series mortality rate was about 69%. Death was often due to multisystem organ failure. Standard mortality ratio (actual mortality over predicted mortality) was 1.58.

Levosimendan was never used as a first line drug; it was always given with norepinephrine and/or dobutamine. Levosimendan was administrated at the dose of 0.1µg/Kg/min during 24 hours without a loading dose to minimize the effect of peripheral vasodilatation and of potentially hypotension.

As for the findings obtained by echocardiography they were as follow: mean left ventricular ejection fraction (LVEF) 35±15%, mean ration E/Ea 11.5±4.8 and mean PAP 50±11.4 mmHg. All these findings were similar in both groups.

To confirm the importance of levosimendan for reducing the rate of death due to cardiogenic shocks we need larger and more homogeneous series and prospective studies.