Introduction: Levosimendan is a novel calcium-sensitising agent that has been proposed as a potentially valuable inotrope for the treatment of acute or decompensated severe heart failure. Early clinical trials described some improvements in surrogate haemodynamic parameters, and suggested a possible survival benefit. However, before concluding that there is a place for routine use of levosimendan in the intensive care unit, a careful appraisal of all available evidence is needed.
The evidence: Two phase II clinical trials, RUSSLAN and LIDO, have shown reduced mortality when levosimendan was compared with placebo and dobutamine, respectively. The CASINO study, yet to be fully reported, also purports to show a beneficial effect of levosimendan. In contrast, the two largest studies, REVIVE and SURVIVE -- also yet to be fully reported -- show no effect of levosimendan.
Conclusions: The best available evidence comes from the two large clinical trials, REVIVE and SURVIVE. These studies suggest that levosimendan does not improve survival for patients with acute severe heart failure. Until their results can be fully scrutinised, and placed in the context of all available evidence, we should conclude that there is no place for levosimendan in the ICU.