Abstract
To compare effects of levosimendan on brain natriuretic factor (BNP) and other myocardial injury indicators in heart failure (HF) patients with chronic atrial fibrillation (AF) versus sinus rhythm (SR). This study was prospective, double blinded and included a total of 62 chronic HF patients in NYHA III-IV classes. Left ventricular ejection fraction £35%, and with either SR (n=38) or AF (n=24) received a 12 μg/kg dose of levosimendan. Then they were followed up by IV infusions, as tolerated. BNP, cardiac troponin I, creatinine kinase-myocardial band levels were measured. Age mean (67.5 ± 16.5 years), demographic features and medical history were not significantly different between groups. Diastolic blood pressure was lower (p=0.008), whereas blood urea nitrogen was higher (p =0.03) in the AF group. The frequently used concomitant medication in the AF group was amiodarone (p=0.02). Both systolic and diastolic blood pressures were decreased in the SR Group (p=0.009 and 0.006, respectively). Despite the reduction in systolic blood pressure (p=0.04), diastolic blood pressure remained unchanged in the AF group. Levosimendan significantly decreased BNP levels in the SR group (p=0.002). There was symptomatic improvement and decrease in the NYHA classification among patients in both groups, but no significant difference between groups. Levosimendan did not reduce BNP levels in patients with AF patients, which might be considered as an indicator of a limited efficacy of levosimendan on decompensated, acute HF patients with AF, compared to patients with SR. Key words: Atrial fibrillation, Brain Natriuretic Peptide (BNP), heart failure, levosimendan, myocardial injury.
Highlights
Heart failure (HF) is among the leading causes of death in developed countries
Considering blood biochemistry and cardiac markers, there was no difference between the two groups for initial values except blood urea nitrogen (BUN), that was higher in the atrial fibrillation (AF) group (p =0.03) (Table 1)
When the patients were assessed for concomitant medications (ACEIs, angiotensin receptor blockers (ARBs), beta-blockers, diuretics, antiplatellets/ anticoagulants, digoxin and amiodarone) they had been using before levosimendan, there was a significant difference between groups only for amiodarone which was found to be used by significantly more patients in the AF group (p=0.02) (Table 2)
Summary
Heart failure (HF) is among the leading causes of death in developed countries. Nowadays, the prognosis of HF progressively worsens, despite the wide use of angiotensin-converting enzyme inhibitors (ACEI), aldosterone antagonists and beta blockers. Intravenous inotropic agents are one of the effective treatment options for patients with advanced decompensation and the use of new positive inotropic agents has decreased the incidence of periodic hospitalization (Silva-Cardoso et al, 2009). Levosimendan therapy is widely being used in patients with decompensated HF (New York Heart Association (NYHA) Class III-IV). Levosimendan is a positive inotropic agent with inodilator effects that enhances the susceptibility of myocardial cells to Ca2+ without increasing the level of intracellular Ca2+ (Mac Gowan, 2005). Both the drug itself and its metabolites have positive inotropic effect in patients with HF (Gross and Fryer, 2000). Compared to the standard inotropic agents, it is well tolerated and has a side effect profile similar to placebo at the recommended doses (Follath et al, 2002; Moiseyev et al, 2002)
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