Effects of levosimendan for low cardiac output syndrome in critically ill patients: systematic review with meta-analysis and trial sequential analysis

Geert Koster*, Jorn Wetterslev, Christian Gluud, Jan G. Zijlstra, Thomas W. L. Scheeren, Iwan C. C. van der Horst, Frederik Keus

*Corresponding author for this work

Research output: Contribution to journalReview articleAcademicpeer-review

43 Citations (Scopus)

Abstract

Purpose: 

To assess the benefits and harms of levosimendan for low cardiac output syndrome in critically ill patients. 

Methods: 

We conducted a systematic review with meta-analyses and trial sequential analyses (TSA) of randomised clinical trials comparing levosimendan with any type of control. Two reviewers independently assessed studies for inclusion. The Cochrane Collaboration methodology was used. Random-effects risk ratios (RR) and 95 % confidence intervals (CI) were derived for the principal primary outcome mortality at maximal followup. 

Results: 

A total of 88 trials were included in the systematic review and 49 trials (6,688 patients) in the meta-analysis. One trial had low risk of bias and nine trials (2,490 patients) were considered lower risk of bias. Trials compared levosimendan with placebo, control interventions, and other inotropes. Pooling all trials including heterogenous populations was considered inappropriate. Pooled analysis of 30 trials including critically ill patients not having cardiac surgery showed an association between levosimendan and mortality (RR 0.83, TSA-adjusted 95 % CI 0.59-0.97), while trials with lower risk of bias showed no significant difference (RR 0.83, TSA-adjusted 95 % CI 0.48-1.55). Conventional meta-analysis of all 14 trials including cardiac surgery patients showed an association, while lower risk of bias trials showed no association between levosimendan and mortality (RR 0.52, 95 % CI 0.37-0.73 versus RR 1.02, 95 % CI 0.48-2.16). 

Conclusions: 

The available evidence is inconclusive whether or not levosimendan may have a beneficial effect on mortality due to risks of systematic errors and random errors. Further well-designed randomised trials are needed.

Original languageEnglish
Pages (from-to)203-221
Number of pages19
JournalIntensive Care Medicine
Volume41
Issue number2
DOIs
Publication statusPublished - Feb-2015

Keywords

  • Heart failure
  • Mortality
  • Cardiac surgery
  • Cardiotonic agents
  • Levosimendan
  • Meta-analysis
  • Trial sequential analysis
  • DECOMPENSATED HEART-FAILURE
  • CORONARY-ARTERY-BYPASS
  • RANDOMIZED CONTROLLED-TRIALS
  • LEFT-VENTRICULAR FUNCTION
  • CALCIUM SENSITIZER LEVOSIMENDAN
  • ACUTE MYOCARDIAL-INFARCTION
  • REDUCES MORTALITY
  • CUMULATIVE METAANALYSIS
  • MONITORING BOUNDARIES
  • EMPIRICAL-EVIDENCE

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