Makindo Medical Notes

⚠️ 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 mcg/kg IV over 10 mins (omit if hypotensive), then infusion at 0.05–0.2 mcg/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

• Levosimendan: current data, clinical use and future development
• BNF (specialist use)