Levosimendan 💊
⚠️ Specialist use only – limited to Consultant Cardiologists and Intensivists.
Levosimendan is a calcium sensitizer and K-ATP channel opener, used in acute decompensated heart failure.
It offers inotropy without increased arrhythmia risk and may improve survival in selected patients.
📖 About
- Check BNF or equivalent for up-to-date prescribing advice (not widely available in the UK).
- Evidence base is mixed – some trials show improved haemodynamics and reduced BNP, others no mortality benefit.
⚡ Mode of Action
- Positive inotrope: Increases cardiac contractility by sensitising troponin C to calcium (does not ↑ intracellular Ca²⁺).
- Vasodilator: Opens ATP-dependent potassium channels in vascular smooth muscle → reduces preload & afterload.
- Unique property: Improves contractility without significantly increasing myocardial oxygen consumption.
- Has long-acting metabolites → effect can persist for 7–9 days after infusion.
💊 Indications & Dose
- Indication: Acute decompensated heart failure due to left ventricular systolic dysfunction.
- Dosing: Loading dose 6 micrograms/kg IV over 10 mins (omit if hypotensive), then infusion at 0.05–0.2 micrograms/kg/min for 24 h.
- Other reported uses: Cardiogenic shock, post-cardiac surgery low-output states, septic shock, Takotsubo cardiomyopathy (off-label).
🤝 Interactions
- Refer to BNF – caution with other vasodilators, antihypertensives, and agents causing hypokalaemia.
⚠️ Cautions
- Hypotension or hypovolaemia (potent vasodilator).
- Renal or hepatic impairment (metabolite clearance affected).
- Monitor electrolytes (esp. potassium).
🚫 Contraindications
- Severe hypotension (SBP < 85 mmHg).
- Tachyarrhythmias or recent ventricular arrhythmia.
- Severe renal or hepatic failure.
💥 Side Effects
- Hypotension, headache, tachycardia.
- Atrial fibrillation, hypokalaemia, nausea.
- Occasionally dizziness, insomnia.
💡 Teaching Pearl
Unlike dobutamine (β-agonist) and milrinone (PDE-3 inhibitor), levosimendan does not increase intracellular calcium.
This means it improves contractility without the same pro-arrhythmic burden.
📚 References
