Letter to the Editor
Effects of levosimendan versus dobutamine on long-term survival of patients with cardiogenic shock after primary coronary angioplasty

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Abstract

Background

Cardiogenic shock (CS) after ST elevation myocardial infarction (STEMI) worsens patient's outcome. Levosimendan treatment offers short-term survival benefit in acute heart failure but its effect on long-term outcome remains unclear. We sought to assess the effect on long-term survival of levosimendan compared to dobutamine treatment in patients with STEMI revascularized by primary coronary angioplasty (PCI) who subsequently developed CS.

Methods and results

Twenty-two consecutive STEMI patients with CS after PCI randomized to receive levosimendan or dobutamine treatment for 24 h were followed-up for twelve months. Complete follow-up was obtained in 100% of them. The endpoint was cardiac death. Baseline clinical and haemodynamic characteristics were similar in both groups. The probability of survival calculated with Kaplan–Meier curves analysis showed no statistically significant differences between both groups (p = 0.24).

Conclusions

Levosimendan compared to dobutamine did not improve long-term survival in STEMI patients revascularized by PCI who developed CS.

Introduction

The development of cardiogenic shock (CS) after ST elevation myocardial infarction (STEMI) worsens patient's outcome. The most effective management strategy is early revascularization [1]. However, despite appropriate intervention, CS continues to be associated with a high mortality rate [2] and often requires inotropic support. Catecholamines and phosphodiesterase inhibitors may have potentially deleterious effects especially in STEMI patients [3]. Levosimendan has been recommended for short-term treatment of acute decompensated heart failure (HF) [4]. Recently, we have showed that levosimendan treatment extended its short-term effectiveness on haemodynamics in CS complicating STEMI revascularized by primary angioplasty (PCI) [5]. Nevertheless, information about its effect on long-term outcome is scarce. The purpose of this study was to assess the effect of levosimendan compared to dobutamine treatment on long-term outcome in STEMI patients with CS.

Section snippets

Patients and methods

Study design has been described in detail elsewhere [5]. Briefly, between January 2003 and December 2004, 180 patients with STEMI were treated in our hospital with PCI. Twenty-six (14%) of them developed CS after PCI. Four patients were excluded due to sustained ventricular tachycardia (n = 1), right ventricular infarction (n = 2), and significant ischemic mitral regurgitation (n = 1). The patients were open-label randomized, in a 1:1 ratio, to receive a 24 h infusion of either levosimendan (loading

Results

Twenty-two patients, aged between 52 and 77 years, admitted with STEMI developed CS within the following 24 h of a successful PCI. Eleven patients were assigned to levosimendan and eleven to dobutamine treatment. Baseline clinical and haemodynamic characteristics, showed in Table 1, were similar in both groups. The levosimendan treatment group showed a higher proportion of anterior infarctions with involvement of the anterior descending coronary artery but without statistically significant

Discussion

The main finding of our study was that levosimendan, although it increased LVEF at short-term significantly more than dobutamine, did not improve long-term outcome versus dobutamine in STEMI patients with CS secondary to severe left ventricular systolic dysfunction after PCI. This finding contrasts with the survival benefits of levosimendan compared to dobutamine or placebo reported in previous trials [3]. However, even though some of these trials included acute HF patients, little information

Acknowledgment

The authors wish to express their gratitude to Ines Abreu-Afonso for the linguistic aids in preparing the manuscript.

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