To the Editor:
The question posed by the authors is interesting, although at the same time disappointing, because at no point do they suggest an answer. In order to provide an answer, it would have been necessary to be aware of our situation: the patient with acute heart failure (AHF) in Spanish emergency wards presents a different profile to the patient usually seen on the cardiology ward or in the office, and even different to the patients who form the object of the guidelines for AHF. A recent multicenter study carried out in Spain1 comes to the conclusion that patients with AHF in the emergency ward are older (a population considered by the guidelines to be special), and have a high degree of comorbidity, functional, and social deterioration, and previous diagnoses of chronic heart failure (CHF), as well as presenting functional decompensation or progression even though most of them receive a correct pharmacological treatment. Moreover, as they are patients with CHF, most are unaware of the type and degree of cardiac dysfunction, and when this is known, both systolic and diastolic dysfunction are predominant. Fewer than 3% undergo an echocardiographic study in the emergency wards, and fewer than 10% are admitted to the cardiology ward, which shows that AHF is very important in the emergency wards and that the treatment of these patients is no less important.
The clinical practice guidelines on AHF must be understood to provide advice on the management of these patients, and we should be able to adapt this advice to the circumstances of our environment and not treat it as dogma for the attendance of our patients. Our working protocol coincides with the current recommendations drawn up by experts in cardiology, emergency medicine and intensive medicine for the early stages of AHF, during which levosimendan is administered to patients who remain symptomatic after initial conventional therapy and in the case of shock associated with vasopressors.2,3
There are currently more than 3000 patients who have been included in randomized clinical trials, in whom the efficacy and safety of levosimendan have been demonstrated, without mentioning observational studies and case series. It is the first inodilatator to improve diastolic dysfunction and left ventricular filling pressures and increases contractility with little consumption of energy, all of which are ideal effects for the different
scenes found with AHF in the emergency department, independently of the type of cardiac dysfunction. Its use in cardiogenic shock is documented in different studies and in the recent recommendations arising from expert agreements.2,3