Italian heart journal : official journal of the Italian Federation of Cardiology
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In the present review striking data showing that intensive care unit patients with acute heart failure and high-risk surgical patients may markedly benefit from the use of levosimendan are presented. Indeed, levosimendan is an effective new agent that acts via two complementary mechanisms. It enhances cardiac contractility by improving the response of the myofilaments to intracellular calcium, and it reduces the cardiac workload by opening the adenosine triphosphate-dependent potassium channels for the dilation of blood vessels. ⋯ In addition, levosimendan has the potential of supporting the cardiac function during the initiation of beta-blocker therapy, for weaning patients from cardiopulmonary bypass, for individuals with valvular abnormalities and for those with myocarditis. Preliminary results also suggest that levosimendan may be beneficial for the treatment of patients with right ventricular heart failure. Although the use of levosimendan has been fully validated for the most common causes of acute heart failure, additional clinical trials are needed to safety broaden its therapeutic indications.
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The management of the failing heart represents an increasingly frequent challenge to both anesthesiologists and intensive care physicians, due to the increased prevalence of ventricular dysfunction in the population and to the ever-expanding indications for the surgical treatment of cardiac disease. Inotropic drugs are nowadays invaluable therapeutic tools in the treatment of perioperative heart failure and of the different forms of heart failure found in intensive care unit clinical practice. Postoperative myocardial dysfunction is a major concern in the setting of cardiac surgery since it is extremely frequent and is related to a greater morbidity and mortality. The different forms of heart failure, the rationale and the indications for the use of inotropic drugs in anesthesiology and intensive care are discussed in this review.
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Randomized Controlled Trial Multicenter Study Comparative Study Clinical Trial
Levosimendan in patients with low-output heart failure: lessons from the LIDO trial.
The novel calcium sensitizer levosimendan improves myocardial contractility without causing an increase in intracellular calcium and cyclic adenosine monophosphate concentrations. It also has a vasodilator action due to an opening of the adenosine triphosphate-sensitive potassium channels. In a double-blind clinical trial levosimendan was compared with dobutamine in 203 patients with severe low-output congestive heart failure. ⋯ Levosimendan also reduced the 1- and 6-month mortality more than dobutamine (7.8 vs 17%, p = 0.045 and 26 vs 38%, p = 0.029, respectively). Levosimendan produced less myocardial ischemia and cardiac arrhythmias than dobutamine. Calcium sensitizers offer a new therapeutic possibility in patients with decompensated low-output heart failure.
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Multicenter Study Comparative Study
Prevalence, clinical characteristics, resource utilization and outcome of patients with acute chest pain in the emergency department. A multicenter, prospective, observational study in north-eastern Italy.
The evaluation and triage of patients with suspected myocardial ischemia in the emergency department is challenging and costly. In Italy there are no prospective data neither about the prevalence, clinical characteristics, and outcome of patients with chest pain in the emergency room, nor about the costs of their triage. Therefore, this study was undertaken to evaluate the diagnostic accuracy and costs of the actual emergency department triage modalities of patients with acute chest pain. ⋯ Data obtained from our multicenter observational study suggest that present triage modalities for patients with chest pain in the emergency department based on patient history, clinical data, electrocardiography, and myocardial injury marker assessment could be improved in terms of accuracy and efficacy. Our data provide the clinical and economical framework for the designation of trials of new accelerated critical pathways for chest pain evaluation in the emergency department.
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Levosimendan is a new vasodilator agent with properties which improve cardiac contractility by calcium sensitization. Its dose-related efficacy and prolonged action have been documented in several major studies both against placebo and dobutamine. Out of 997 patients, 837 (84%) had acute or stable heart failure due to coronary heart disease. ⋯ No increase in arrhythmias is seen. The hemodynamic effects of levosimendan are dose-dependent and the current recommended doses are safe. No increase in mortality or any life-threatening arrhythmias have been observed.