Levosimendan: current status and future prospects

PURPOSE OF REVIEW: While patients with acute heart failure typically receive diuretics and vasodilators, contractile dysfunction and peripheral hypoperfusion also leads to a widespread use of inotropic agents despite the lack of evidence for efficacy or safety. Levosimendan, a calcium sensitizer and vasodilator, has been proposed to be superior to standard inotropes. In addition, further possible indications for levosimendan have been described, such as perioperative use, cardioprotection, cardiogenic shock, sepsis, and right ventricular dysfunction. RECENT FINDINGS: The mortality benefit of levosimendan has not been confirmed in two recent trials but the substance improves symptoms, decreases brain natriuretic peptide and is effective during beta-blocker treatment. The use of levosimendan as an add-on therapy in acute heart failure has been encouraged as well as its perioperative use. Levosimendan may also be useful during right ventricular dysfunction and septic shock due to its favorable effects on splanchnic perfusion. SUMMARY: Levosimendan is an established substance in the treatment of acute heart failure in several countries despite disappointing findings concerning a possible survival benefit in two recent clinical trials. Owing to its alternative mechanisms of action as compared with traditional cardiotonic agents, several promising clinical applications have arisen. Available evidence for the use of levosimendan in settings other than decompensated heart failure is currently limited.