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

Levosimendan, a calcium sensitizer, was used in combinationwith ß-adrenergic antagonists in a man aged 56 yrwith 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 µg kg^–1 min^–1and dobutamine 5 µg kg^–1 min^–1, titrated toa mean arterial pressure 65 mm Hg. He progressively became tachycardiac(>120 beats min^–1) with a cardiac index (CI) of 1.4litre min^–1 m^–2 despite adequate preload. Levosimendan6 µg kg^–1 was administered intravenously over 10min followed by a continuous infusion of 0.2 µg kg^–1min^–1 for 24 h. Within 30 min, the patient's CI increasedto 2.2 litre min^–1 m^–2, but the heart rate (HR)also increased from 142 to 155 beats min^–1. Esmolol 1mg kg^–1 i.v. was administered with a consequent transientdecrease in HR to 110 beats min^–1 without adverse haemodynamiceffects; however, HR increased again shortly afterwards. Carvedilol3.125 mg orally twice a day was then administered, and the dosewas increased to 6.25 mg orally twice daily on the followingday. Subsequently, HR decreased over time and both catecholamineswere discontinued 14 h after starting levosimendan infusion.The trachea was extubated within 20 h and the patient was dischargedto the ward on day 4 after admission. In conclusion, levosimendanin combination with a ß-adrenergic antagonist mayhave beneficial effects in patients with cardiogenic shock whoexhibit tachycardia in response to inotropic agents.