Levosimendan in Cardiogenic Shock — EECC MCQ

Correct answer: B — Levosimendan — a calcium sensitiser and K-ATP channel opener that improves contractility without increasing intracellular calcium or myocardial oxygen demand; it also has vasodilatory properties

Levosimendan is the correct option. In acute decompensated HFrEF with cardiogenic shock, inotropic support is a monitored critical-care intervention, used for low-output hypotension/shock rather than routine acute heart failure. Levosimendan is an inodilator: it sensitises cardiac troponin C to calcium and opens ATP-sensitive potassium channels, increasing contractility and cardiac output while reducing preload/afterload through systemic and pulmonary vasodilation. Because it does not rely on beta-adrenergic stimulation or increasing intracellular calcium, it is less likely than catecholamine inotropes such as dopamine or dobutamine to drive tachyarrhythmia and myocardial oxygen demand. It can still cause hypotension and arrhythmias, so it is not “risk-free” and should be used with specialist monitoring; in hypotensive patients a loading bolus is generally avoided. Dopamine is not preferred in all cardiogenic shock and is proarrhythmic at higher doses; milrinone has proarrhythmic potential and vasodilatory hypotension risk; dobutamine is a beta-agonist and can increase heart rate, oxygen demand and arrhythmias; IV digoxin is too slow and weak for acute shock inotropic rescue.

Reference: McDonagh TA et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal 2021;42:3599–3726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045