Effects of levosimendan on circulating pro-inflammatory cytokines and soluble apoptosis mediators in patients with decompensated advanced heart failure

Effects of Levosimendan on Circulating Proinflammatory Cytokines and Soluble Apoptosis Mediators in Patients With Decompensated Advanced Heart Failure John T. Parissis, MD, Stamatis Adamopoulos, MD, Charalambos Antoniades, George Kostakis, MD, Antonios Rigas, MD, Stamos Kyrzopoulos, MD, Efstathios Iliodromitis, MD, and Dimitrios Kremastinos, MD This randomized, placebo-controlled trial showed that levosimendan administration causes a significant reduction of circulating proinflammatory cytokine interleukin-6 and soluble apoptosis mediators, such as soluble Fas and Fas ligand in patients with decompensated heart failure. These immunomodulatory effects may lead to improvement of symptoms and echocardiographic markers of cardiac contractile performance in these patients. 䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:1309 –1312)

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evosimendan, a novel calcium sensitizer, improves cardiac contractility without increasing myocardial oxygen demand or promoting arrhythmiogenesis, possibly through the stabilization of troponin-C in a configuration that enhances the calcium sensitivity of cardiac myofilaments.1,2 In patients with severe lowoutput heart failure, levosimendan improved hemodynamic performance more effectively than dobutamine, accompanied by lower long-term mortality.3 However, the effects of levosimendan on circulating proinflammatory cytokines and soluble apoptosis mediators in patients with decompensated severe heart failure are unknown. In the present study, we examined the anti-inflammatory and antiapoptotic properties of levosimendan in these patients, and we searched for possible correlations with the drug-induced improvement in left ventricular (LV) contractile performance. •••

The study population consisted of 27 patients with systolic LV dysfunction and New York Heart Association class III or IV symptoms of heart failure. Patients were currently on treatment with angiotensinconverting enzyme inhibitors and diuretics and had documented LV ejection fractions of ⱕ30% and a cardiac index ⱕ2.5 L/min/m2. Some of the patients also received ␤ blockers, an aldosterone antagonist, and amiodarone. Exclusion criteria were acute or chronic infectious or inflammatory diseases, recent myocardial infarction (⬍8 weeks) or active ischemia, hepatic or renal impairment (creatinine ⬎2.5 mg/dl), From the Second Department of Cardiology, Amalia Fleming Hospital; and Second Department of Cardiovascular Medicine, Onassis Cardiac Surgery Center, Athens, Greece. Dr. Parissis’ address is: Riga Ferreou Str 18-20, 15122, Maroussi, Athens, Greece. E-mail: [email protected]. Manuscript received November 19, 2003; revised manuscript received and accepted January 23, 2004. ©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 May 15, 2004

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TABLE 1 Baseline Characteristics of Decompensated Advanced Heart Failure Patients Levosimendan-treated Placebo-treated Group Group (n ⫽ 13) (n ⫽ 14)

Variable Age (yrs) Cause of heart failure Ischemic Dilated Ejection fraction (%) New York Heart Association classes III/IV Cardiac index (L/min/m2) Medication Angiotensin-converting enzyme inhibitors Diuretics ␤ blockers Aldosterone antagonist Amiodarone

72 ⫾ 2

69 ⫾ 3

10 3 26 ⫾ 2 5/8

10 4 28 ⫾ 1 6/8

2.0 ⫾ 0.3

2.1 ⫾ 0.3

13

14

13 5 6 4

14 6 8 4

Values expressed as means ⫾ SEM. There were no significant differences between the 2 groups.

use of immunosuppressive drugs, serious arrhythmias, and supine systolic blood pressure ⬍85 mm Hg. The study was approved by the institutional ethics committee, and written consent was given by each patient. Patients were randomized to receive intravenous levosimendan (n ⫽ 13) or placebo (n ⫽ 14). Levosimendan was given as a 10-minute intravenous bolus of 6 ␮g/kg followed by continuous infusion, initially at a rate of 0.1 ␮g/kg/min. Up-titration was done until a maximum rate of 0.4 ␮g/kg/min was achieved or a dose-limiting event occurred, as previously described.4,5 The groups were similar with regard to age and gender distribution, cause of heart failure, functional status, and echocardiographic and hemodynamic indexes of LV systolic dysfunction (Table 1). Symptoms were evaluated by both the patient and physician at baseline, 6 hours after the initiation of treatment, at the end of treatment, and 48 hours later, as previously described.4,5 LV dimensions, ejection fraction, and end-systolic wall stress6 were calculated by echocardiography at baseline and 48 hours after levosimendan or placebo treatment. Hemodynamics were measured with a Swan-Ganz catheter. Cardiac output and index were determined by the thermodilution technique. Serum samples were assayed in duplicate for proinflammatory cytokines tumor necrosis 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2004.01.073

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TABLE 2 Effects of Levosimendan and Placebo Treatment on Echocardiographic Indexes, Circulating Proinflammatory Cytokines and Soluble Apoptosis Markers in Patients With Decompensated Heart Failure Levosimendan-treated Group (n ⫽ 13) Variable Ejection fraction (%) Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Wall stress (g/cm2) LV end-diastolic diameter (cm) LV end-systolic diameter (cm) TNF-␣ (pg/ml) IL-6 (pg/ml) Soluble Fas (ng/ml) Soluble Fas ligand (pg/ml)

Before 26 109 69 783 6.94 5.92 12.97 12.69 6.95 69.29

⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾

After

2 5 4 67 0.97 0.18 1.46 1.65 0.98 5.26

31 112 70 662 7.00 5.59 11.42 10.98 5.86 60.57

⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾

3† 6 4 72 0.08 0.27† 1.92 1.58* 0.99* 5.16*

Placebo-treated Group (n ⫽ 14) Before 28 119 74 721 6.386 5.057 12.24 10.46 6.42 67.16

⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾

1 5 3 49 0.112 0.128 1.803 1.08 0.58 5.08

After 27 115 74 739 6.443 5.078 13.11 10.71 6.73 68.04

⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾

2 6 3 50* 0.157 0.141 1.917* 1.24 0.67 5.01

Values expressed as mean ⫾ SEM. There were no significant differences between the groups at baseline. *p ⬍0.05; †p ⬍0.01 before versus after treatment.

tions between variables were detected by Pearson’s coefficient. Changes in the examined parameters by the treatment were assessed by analysis of variance for repeated measurements. A p value ⬍0.05 was considered statistically significant. At baseline, end-systolic wall stress was correlated with serum TNF-␣ (r ⫽ 0.683, p ⫽ 0.0001), IL-6 (r ⫽ 0.451, p ⫽ 0.018), soluble Fas (r ⫽ 0.429, p ⫽ 0.026), and soluble Fas ligand (r ⫽ 0.494, p ⫽ 0.009). Forty-eight hours after levosimendan treatment, symptoms (dyspnea and fatigue) were improved in the levosimendan group (p ⬍0.05 vs placebo), with more patients reporting improvement in symptoms (54% vs 22%) and fewer reporting worsening (16% vs 33%). LV ejection fraction was significantly increased in the levosimendan-treated group (p ⬍0.01), whereas it remained unafFIGURE 1. Effects of levosimendan on proinflammatory cytokines and apoptotic markfected in the placebo group (p ⫽ NS) ers. Serum levels of TNF-␣ were slightly decreased in the levosimendan-treated group but significantly increased in the placebo group (A). Serum levels of IL-6 (B), soluble (Table 2). End-systolic wall stress Fas (sFas) (C), and soluble Fas-ligand (sFas-ligand) (D) were significantly decreased in was decreased in the levosimendanthe levosimendan-treated group but remained unchanged in the placebo-treated treated group (p ⬍0.05), whereas it group; Black bars, before treatment; white bars, after treatment. *p <0.05 after verwas slightly but not significantly insus before treatment. creased in the placebo-treated group (p ⫽ NS) (Table 2). Serum levels of IL-6 and soluble Fas and Fas ligand factor-␣ (TNF-␣), interleukin-6 (IL-6), and soluble were also decreased in the levosimendan-treated Fas and Fas ligand concentrations using commercially group (p ⬍0.05 for all) but not in the placebo group (p available enzyme-linked immunosorbent assay kits ⫽ NS for all) (Table 2 and Figure 1). The changes in (R&D Systems, Minneapolis, Minnesota, for TNF-␣, serum IL-6, soluble Fas and Fas ligand were signifiIL-6, and soluble Fas; Diaclone kit, Besancom, cantly greater in the levosimendan-treated group compared with the changes in the placebo-treated group (p France, for soluble Fas ligand). All values were expressed as mean ⫾ SEM. Un- ⬍0.05 for all). Serum TNF-␣ was slightly but not paired Student’s t test was used to evaluate the differ- significantly decreased in the levosimendan-treated ences in variables between the 2 treated groups at group (p ⫽ NS), whereas it was significantly inbaseline, whereas comparisons between qualitative creased in the placebo group (p ⬍0.05) (Table 2 and variables were performed by chi-square test. Correla- Figure 1). However, the decrease of TNF-␣ levels in 1310 THE AMERICAN JOURNAL OF CARDIOLOGY姞

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FIGURE 2. The change in LV end-systolic wall stress was significantly correlated with the changes in serum levels of TNF-␣ (A) and soluble Fas ligand (sFas-L) (B).

levosimendan-treated group was significantly different compared with the increase in placebo-treated group (p ⬍0.05). The observed changes in LV end-systolic wall stress were significantly correlated with the changes in serum levels of TNF-␣ (r ⫽ 0.629, p ⫽ 0.001) (Figure 2), IL-6 (r ⫽ 0.506, p ⫽ 0.008), soluble Fas (r ⫽ 0.468, p ⫽ 0.024), and soluble Fas ligand (r ⫽ 0.634, p ⫽ 0.001) (Figure 2). •••

In this study, we have focused for the first time on the underlying mechanisms (inflammatory and apoptotic processes) mediating clinical improvement after levosimendan treatment in patients with heart failure. We examined the effects of levosimendan not only on symptoms and hemodynamic status of patients with decompensated heart failure but also on echocardiographic indexes of cardiac contractile performance and representative inflammatory and apoptotic markers associated with the deterioration of this syndrome.7–10 A significant reduction of end-systolic wall stress and an increase of LV ejection fraction were found in levosimendan-treated patients compared with the placebotreated group. This might be a result of drug-induced enhancement of cardiac contractility and attenuation of peripheral vasoconstriction. Additionally, levosimendan treatment caused a significant reduction in major proinflammatory cytokine IL-6 and a slight decrease of TNF-␣, which orchestrates the abnormal immune reactions in heart failure, depress cardiac functional capacity, and promote cardiomyocyte apoptosis and maladaptive LV remodeling.7,8,11,12 Anti-inflammatory effects of le-

vosimendan, combined with the absence of intracellular calcium overloading into cardiomyocytes,2 may also lead to downregulation of apoptosis signaling pathways in the failing heart, as expressed by the levosimendaninduced reduction in soluble Fas/Fas ligand system. Cross-linking of soluble receptor Fas with Fas ligand is followed by intracellular calcium homeostasis alterations, caspase activation, apoptotic gene transcription and, finally, apoptotic cell death.9,10 Significant correlations between the attenuation of peripheral immune responses and the apoptotic process and the improvement of LV contractile performance were found, indicating that levosimendan intervenes in vicious circles of hemodynamic and neuroendocrine dysfunction of decompensated heart failure, inhibiting the stimuli for myocardial cytokine production and spillover into circulation, possibly through the attenuation of decreased intracellular calcium sensitivity.2 Our findings differ slightly from those of Behrends and Peters,13 who found that although levosimendan markedly improved LV contractility in hearts from endotoxic and sham animals, it failed to specifically abolish endotoxin-evoked myocardial dysfunction, indicating that decreased calcium sensitivity does not play a major role in endotoxin-evoked cardiomyopathy. In addition to the potential calcium homeostasis-related direct effects of levosimendan on cardiac cytokine production, levosimendan-induced improvement of systolic function and peripheral vasorelaxation may also attenuate peripheral tissue hypoperfusion leading to downregulation of cytokine extra-cardiac production by transcriptional factors such us NF-␬B.7,8,14,15 Sustained anti-inflammatory effects of levosimendan (48 hours after infusion) may be explained by the release of its active metabolite OR1896, which has a much longer elimination half-life (⬃70 to 80 hours) than the drug itself.1 Immunomodulatory effects of levosimendan may be additional pathophysiologic mechanisms that prevent further clinical and hemodynamic consequences of abnormal immune responses in decompensated heart failure,16,17 beneficially affecting the progression of the syndrome. Our results are preliminary, and further studies are needed to investigate the long-term effects of levosimendan on the peripheral inflammatory process, as well as to compare this agent with other traditionally used inotropic drugs in decompensated heart failure. 1. Kivikko M, Antila S, Eha J, Lehtonen L, Pentikainen P. Pharmacodynamics

and safety of a new calcium sensitizer, levosimendan, and its metabolites during an extended infusion in patients with severe heart failure. J Clin Pharmacol 2002;42:43–51. 2. Hasenfuss G, Pieske B, Castell M, Kretschmann B, Maier LS, Just H. Influence of the novel inotropic agent levosimendan on isometric tension and calcium cycling in failing human myocardium. Circulation 1998;98:2141–2147. 3. Follath F, Cleland JG, Just H, Papp JG, Scholz H, Peuhkuinen K, Harjola VP, Mitrovic V, Abdalla M, Sandell EP, Lehtonen L. Efficacy and safety of intravenous levosimendan compared with dobutamine in severe low-output heart failure (the LIDO study: a randomized double-blind trial). Lancet 2002;360:196 –202. 4. Slawsky MT, Colucci WS, Gottlieb SS, Greenberg BH, Haeusslein E, Hare J, Hutchins S, Leier CV, Lejemtel TH, Loh E, et al. Acute hemodynamic and clinical effects of levosimendan in patients with severe heart failure. Circulation 2000;102:2222–2227. 5. Kivikko M, Lehtonen L, Colucci WS. Sustained hemodynamic effects of intravenous levosimendan. Circulation 2003;107:81–86. 6. Gould KL, Lipscomb K, Hamilton GW, Kennedy JW. Relation of left ventricular shape, function and wall stress in man. Am J Cardiol 1974;34:627–634.

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7. Mann DL, Young JB. Basic mechanisms in congestive heart failure: recog-

13. Behrends M, Peters J. The calcium sensitizer levosimendan attenuates endo-

nizing the role of pro-inflammatory cytokines. Chest 1994;105:897–904. 8. Adamopoulos S, Parissis J, Kremastinos D. A glossary of circulating cytokines in chronic heart failure. Eur J Heart Fail 2001;3:517–526. 9. Okuyama M, Yamagouchi S, Nozaki N, Yamaoka M, Shirakabe M, Tomoike H. Serum levels of soluble form of Fas molecule in patients with congestive heart failure. Am J Cardiol 1997;79:1698 –1701. 10. Yamagouchi S, Yamaoka M, Okuyama M, Nitoube J, Fukui A, Shirakabe M, Shirakawa K, Nakamura N, Tomoike H. Elevated circulating levels and cardiac secretion of soluble Fas Ligand in patients with congestive heart failure. Am J Cardiol 1999;83:1500 –1503. 11. Finkel MS, Oddis CV, Jacob TD, Watkins SC, Hattler BG, Simmons RL. Negative inotropic effects of cytokines on the heart mediated by nitric oxide. Science 1992;257:387–389. 12. Sasayama S, Matsumori A, Kihara Y. New insights into the pathophysiological role for cytokines in heart failure. Cardiovasc Res 1999;42:557–564.

toxin-evoked myocardial dysfunction in isolated guinea pig hearts. Intensive Care Med 2003;29:1802–1807. 14. Paulus WJ. How are cytokines activated in heart failure? Eur J Heart Fail 1999;1:309 –312. 15. Yokoshiki H, Katsube Y, Sunagawa M, Sperelakis N. Levosimendan, a novel Ca2⫹-sensitizer activates the glibenclamide-sensitive K⫹ channel in rat arterial myocytes. J Pharmacol Exp Ther 1997;283:375–383. 16. Milani RV, Mehra MR, Endres A, Eigler A, Cooper ES, Lavie CJ Jr, Ventura HO. The clinical relevance of circulating tumor necrosis-alpha in acute decompensated chronic heart failure without cachexia. Chest 1996;110: 992–995. 17. Parissis J, Venetsanou K, Mentzikof D, Ziras N, Kefalas C, Karas S. Tumor necrosis factor-␣ serum activity during treatment of acute decompensation of cachectic and non-cachectic patients with advanced congestive heart failure. Scand Cardiovasc J 1999;33:344 –350.

Usefulness of the Third Heart Sound in Predicting an Elevated Level of B-Type Natriuretic Peptide Gregory M. Marcus, MD, Andrew D. Michaels, MD, Teresa De Marco, Charles E. McCulloch, PhD, and Kanu Chatterjee, MB Third heart sounds were sought in 100 consecutive outpatients who had B-type natriuretic peptide (BNP) levels measured within 8 hours. Mean BNP levels were significantly higher in those with a third heart sound. The presence of a third heart sound was 41% sensitive and 97% specific for elevated BNP levels. 䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:1312–1313)

nlike brain natriuretic peptide (BNP) levels, auscultation of S is free of charge and is immediU ately accessible. Barriers to the widespread use of this 3

clinical tool do not involve finances or technology, but rather involve unfamiliarity with physical diagnosis and unrefined clinical skills. As more sophisticated laboratory tests become available to facilitate and even potentially replace our clinical skills, there is a risk that the teaching and practice of those skills will deteriorate.1,2 Therefore, we sought to answer the question: can auscultation of the third heart sound predict elevated BNP levels? •••

One hundred consecutive adult outpatients presenting to a general cardiology clinic were prospectively studied. A single senior cardiologist (KC), blinded to BNP levels, auscultated for a left ventricular S3 in each patient. After identification of the point of maximal impulse by palpation, auscultation was performed in a quiet room at and around the apex with patients in both the supine and left lateral decubitus positions. Using a point-of-care assay, serum BNP From the Departments of Cardiology and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California. Dr. Marcus’ address is: Department of Cardiology, University of California, San Francisco, M1180D, 505 Parnassus Ave., San Francisco, California 94143-0124. E-mail: [email protected]. Manuscript received December 22, 2003; revised manuscript received and accepted January 29, 2004.

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levels (Biosite, San Diego, California) were collected within 8 hours of the physical examination. A BNP level ⱖ100 pg/ml was prespecified as defining an elevated BNP level.3 All patients gave written informed consent before the BNP testing, and the protocol was approved by the University of CaliforniaSan Francisco Committee on Human Research. From review of clinical charts, the patients’ primary diagnosis and significant co-morbidities were recorded, including coronary artery disease (defined as ⱖ1 coronary artery with ⱖ75% diameter stenosis), hypertension, dilated cardiomyopathy, atrial fibrillation, moderate-to-severe aortic stenosis, moderate-tosevere mitral regurgitation, chronic renal failure, hypertrophic obstructive cardiomyopathy, paroxysmal supraventricular tachycardia, and chronic obstructive pulmonary disease. All available imaging studies for each patient were retrospectively reviewed. For each patient, the most recent imaging study (echocardiography, single positron emission tomography technetium-99m sestamibi, or left ventriculogram from cardiac catheterization) from our institution was used to record left ventricular ejection fraction (EF). Data are presented as mean values and SDs for continuous variables. Comparisons between groups were assessed using exact Mann-Whitney and Fisher’s exact tests, where appropriate. Two-tailed p values ⬍0.05 were considered significant. Twenty-six patients were found to have a third heart sound (Table 1). The BNP level of those with a S3 was 476 ⫾ 290 pg/ml, and the BNP level of those without a S3 was 175 ⫾ 198 pg/ml (p ⬍0.0005; Table 1). Thirty-nine patients had BNP levels ⬍100 pg/ml, and 61 had BNP levels ⱖ100 pg/ml. Using this cutoff (defining elevated BNP levels as those ⱖ100 pg/ml), the presence of an S3 was 41% sensitive and 97% specific for elevated BNP levels. In this patient popula0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2004.01.074