Acute heart failure and/or cardiogenic shock are frequently triggered by ischemic coronary events. Yet, there is a paucity of randomized data on the management of patients with heart failure complicating acute coronary syndrome, as acute coronary syndrome and cardiogenic shock have frequently been defined as exclusion criteria in trials and registries. As a consequence, guideline recommendations are mostly driven by observational studies, even though these patients have a particularly poor prognosis compared to heart failure patients without signs of coronary artery disease. In acute heart failure, and especially in cardiogenic shock related to ischemic conditions, vasopressors and inotropes are used. However, both pathophysiological considerations and available clinical data suggest that these treatments may have disadvantageous effects. The inodilator levosimendan offers potential benefits due to a range of distinct effects including positive inotropy, restoration of ventriculo-arterial coupling, increases in tissue perfusion, and anti-stunning and anti-inflammatory effects. In clinical trials levosimendan improves symptoms, cardiac function, hemodynamics, and end-organ function. Adverse effects are generally less common than with other inotropic and vasoactive therapies, with the notable exception of hypotension. The decision to use levosimendan, in terms of timing and dosing, is influenced by the presence of pulmonary congestion, and blood pressure measurements. Levosimendan should be preferred over adrenergic inotropes as a first line therapy for all ACS-AHF patients who are under beta-blockade and/or when urinary output is insufficient after diuretics. Levosimendan can be used alone or in combination with other inotropic or vasopressor agents, but requires monitoring due to the risk of hypotension.

Cardiological Intensive Care Unit Alexandrovski Central Clinical Hospital Kiev Ukraine

Cardiological Intensive Care Unit Cardiological Center Monzino Milan Italy

Critical Care Proprietary Products Orion Pharma Espoo Finland

Department of Anaesthesia and Burn and Critical Care Saint Louis Lariboisière Hospital AP HP University Paris Diderot Paris France

Department of Anesthesiology University Hospitals Leuven Leuven Belgium

Department of Cardiology 2 Niguarda Ca' Granda Hospital Milan Italy

Department of Cardiology Alexandra General Hospital of Athens Athens Greece

Department of Cardiology Coimbra Hospital and University Centre Coimbra Portugal

Department of Cardiology Lariboisière Hospital Paris France

Department of Cardiology North Estonia Medical Center Tallinn Estonia

Department of Cardiology Odense University Hospital Denmark

Department of Cardiology Oslo University Hospital Oslo Norway

Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden

Department of Cardiology University Clinic Lomonosov Moscow State University Moscow Russia

Department of Cardiology University Hospital and Faculty of Medicine Pilsen Charles University Prague Czech Republic

Department of Cardiology University Hospital Virgen Macarena Seville Spain

Department of Cardiology University of Debrecen Debrecen Hungary

Department of Cardiothoracic Anesthesia and Intensive Care University Hospital of Pisa Pisa Italy

Department of Emergency Medicine and Services Helsinki University Hospital Helsinki Finland

Department of Intensive Care and Respiratory Medicine The Royal Brompton and Harefield Hospitals NHS Trust London UK

Department of Intensive Care Medicine Consorci Sanitari Integral University of Barcelona Barcelona Spain

Department of Intensive Internal Medicine University Medical Center Ljubljana Ljubljana Slovenia

Department of Internal Medicine 2 St Marien Hospital Siegen Siegen Germany

Department of Internal Medicine 4 Hietzing Hospital Vienna Austria

Heart and Vascular Center Semmelweis University Budapest Hungary

Heart Center Rigshospitalet Copenhagen Denmark

Helsinki University Central Hospital Helsinki Finland

Jagiellonian University Medical College Faculty of Health Sciences Division of Rescue Medicine Department of Coronary Heart Disease and Heart Failure John Paul 2 Hospital Cracow Poland

Jagiellonian University Medical College Faculty of Medicine Institute of Cardiology Department of Coronary Heart Disease and Heart Failure John Paul 2 Hospital Cracow Poland

Laboratory of Clinical Cardiology Scientific Research Institute of Physical Chemical Medicine Moscow Russia

Royal Devon and Exeter NHS Foundation Trust Exeter UK

University of Dresden Heart Center Dresden University Hospital Dresden Germany

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Levosimendan Efficacy and Safety: 20 Years of SIMDAX in Clinical Use

Levosimendan Efficacy and Safety: 20 years of SIMDAX in Clinical Use