Clinical predictors of all-cause mortality and heart failure readmissions after intermittent levosimendan
R Brandao, F Gerardo, L Cotrim, M Ribeiro, C Henriques, M Passos, A Oliveira Soares, I Fialho, D RoqueAbstract
Background
Advanced heart failure (AdHF) is characterized by a decline in life expectancy, a poor quality of life marked by frequent hospitalizations, and a significant impairment in functional capacity. In these patients, intermittent levosimendan cycles (ILC) have been shown to have clinical and hemodynamic benefits being used as a bridge therapy, to heart transplantation (HT) and left ventricular assist device (LVAD), or as a symptomatic approach.
Objectives
Assess predictors of mortality and hospital readmissions in this AdHF population.
Methods
A retrospective, single-center study including 59 patients with AHF undergoing regular ILC. The primary endpoint was a composite of all-cause mortality or heart failure readmission at 6 months. Binary logistic regression was performed to identify independent predictors of adverse outcomes.
Results
The cohort included 46 men (77%), with a mean age of 67 ± 12.9 years and a median BMI of 25 kg/m² (IQR 21–27). Baseline left ventricular ejection fraction was 24.6% (IQR 19.5–29.5), and median NT-proBNP was 9,805 pg/mL (IQR 3,292–12,310). Regarding guideline-directed medical therapy (GDMT), 88% were on beta-blockers, 43% on sacubitril/valsartan, 33% on ACE inhibitors, 73% on SGLT2 inhibitors, and 82% on mineralocorticoid receptor antagonists. Multivariate logistic regression identified baseline beta-blocker dose (OR 1.36; p=0.027) and baseline furosemide dose (OR 1.03; p=0.025) as independent predictors of worse outcomes. Conversely, treatment with sacubitril/valsartan before levosimendan initiation was associated with a lower likelihood of the composite outcome (OR 0.16; p=0.035), whereas baseline NT-proBNP (OR: 1.00; p=0.036) showed no impact on defined outcomes.
Conclusions
In patients with advanced heart failure treated with regular intermittent levosimendan, parameters reflecting greater congestion were independently associated with poorer 6-month outcomes. Notably, higher baseline beta-blocker dose was also associated with worse prognosis, a finding that likely reflects the limited tolerability of this drug class in the context of advanced heart failure. Conversely, prior treatment with sacubitril/valsartan appeared protective. These results underscore the complex and stage-dependent interaction between guideline-directed medical therapy and inotropic support, highlighting the need for individualized therapeutic strategies and further multicenter studies to refine prognostic stratification in this vulnerable population.