Treatment of cardiogenic shock with levosimendan in combination with β-adrenergic antagonists

Levosimendan, a calcium sensitizer, was used in combination with beta-adrenergic antagonists in a man aged 56 yr with cardiogenic shock, complicating acute myocardial infarction, who developed severe tachycardia after dobutamine administration. The patient's trachea was intubated, his lungs were ventilated, and he was started on dopamine 5 mu g kg(-1) min(-1) and dobutamine 5 mu g kg(-1) min(-1), titrated to a mean arterial pressure >= 65 mm Hg. He progressively became tachycardiac (> 120 beats min(-1)) with a cardiac index (CI) of 1.4 litre min(-1) m(-2) despite adequate preload. Levosimendan 6 mu g kg(-1) was administered intravenously over 10 min followed by a continuous infusion of 0.2 mu g kg(-1) min(-1) for 24 h. Within 30 min, the patient's CI increased to 2.2 litre min(-1) m(-2), but the heart rate (HR) also increased from 142 to 155 beats min(-1). Esmolol 1 mg kg(-1) i.v. was administered with a consequent transient decrease in HR to 110 beats min(-1) without adverse haemodynamic effects; however, HR increased again shortly afterwards. Carvedilol 3.125 mg orally twice a day was then administered, and the dose was increased to 6.25 mg orally twice daily on the following day. Subsequently, HR decreased over time and both catecholamines were discontinued 14 h after starting levosimendan infusion. The trachea was extubated within 20 h and the patient was discharged to the ward on day 4 after admission. In conclusion, levosimendan in combination with a beta-adrenergic antagonist may have beneficial effects in patients with cardiogenic shock who exhibit tachycardia in response to inotropic agents.