Stress cardiomyopathy (SC), first reported in Japan as takotsubo, is characterized by acute, profound, but reversible left ventricular (LV) dysfunction in the absence of significant coronary artery disease, triggered by acute emotional or physical stress.¹ This phenomenon is identified by a distinctive pattern of “apical ballooning” and primarily affects postmenopausal women.^2-5 The majority of patients have a clinical presentation similar to that of acute coronary syndrome (ACS). Accordingly, international guidelines have included SC as an important differential diagnosis of ACS.⁶

Acute respiratory distress syndrome (ARDS) is frequently associated with increased pulmonary vascular resistance and thus with systolic load of the right ventricle. We hypothesized that levosimendan, a new calcium sensitizer with potential pulmonary vasodilator properties, improves hemodynamics by unloading the right ventricle in patients with ARDS. Prospective, randomized, placebo-controlled, pilot study. Twenty-two-bed multidisciplinary intensive care unit of a university hospital. Thirty-five patients with ARDS in association with septic shock. Patients were randomly allocated to receive a 24-hr infusion of either levosimendan 0.2 μg/kg/min (n = 18) or placebo (n = 17). Data from right heart catheterization, cardiac magnetic resonance, arterial and mixed venous oxygen tensions and saturations, and carbon dioxide tensions were obtained before and 24 hrs after drug infusion. At a mean arterial pressure between 70 and 80 mm Hg (sustained with norepinephrine infusion), levosimendan increased cardiac index (from 3.8 ± 1.1 to 4.2 ± 1.0 L/min/m2) and decreased mean pulmonary artery pressure (from 29 ± 3 to 25 ± 3 mm Hg) and pulmonary vascular resistance index (from 290 ± 77 to 213 ± 50 dynes/s/cm5/m2; each p < .05). Levosimendan also decreased right ventricular end-systolic volume and increased right ventricular ejection fraction (p < .05). In addition, levosimendan increased mixed venous oxygen saturation (from 63 ± 8 to 70 ± 8%; p < .01). This study provides evidence that levosimendan improves right ventricular performance through pulmonary vasodilator effects in septic patients with ARDS. A large multiple-center trial is needed to investigate whether levosimendan is able to improve the overall prognosis of patients with sepsis and ARDS.

Background—: cGMP phosphodiesterase type 5 protein is upregulated in myocardial hypertrophy. However, it has never been ascertained whether phosphodiesterase type 5 inhibition exerts an antiremodeling effect in nonischemic heart disease in humans. We explored the cardioreparative properties of a selective phosphodiesterase type 5 inhibitor, sildenafil, in a model of diabetic cardiomyopathy. Methods and Results—: Fifty-nine diabetic men (60.3±7.4 years) with cardiac magnetic resonance imaging consistent with nonischemic, nonfailing diabetic cardiomyopathy (reduced circumferential strain [σ], −12.6±3.1; increased left ventricular [LV] torsion [θ], 18.4±4.6°; and increased ratio of LV mass to volume, 2.1±0.5 g/mL) were randomized to receive sildenafil or placebo (100 mg/d). At baseline, the metabolic indices were correlated with torsion, strain, N-terminal pro–B-type natriuretic peptide, vascular endothelial growth factor, monocyte chemotactic protein-1, and blood pressure. After 3 months, sildenafil produced a significant improvement compared with placebo in LV torsion (Δθ: sildenafil, −3.89±3.11° versus placebo, 2.13±2.35°; P <0.001) and strain (Δσ: sildenafil, −3.30±1.86 versus placebo, 1.22±1.84; P <0.001). Sildenafil-induced improvement of LV contraction was accompanied by consistent changes in chamber geometry and performance, with a 6.5±11 improvement in mass-to-volume ratio over placebo ( P =0.021). Monocyte chemotactic protein-1 and transforming growth factor-β were the only markers affected by active treatment (Δmonocyte chemotactic protein-1: −75.30±159.28 pg/mL, P =0.032; Δtransforming growth factor-β: 5.26±9.67 ng/mL, P =0.009). No changes were found in endothelial function, afterload, or metabolism. Conclusions—: The early features of diabetic cardiomyopathy are LV concentric hypertrophy associated with altered myocardial contraction dynamics. Chronic phosphodiesterase type 5 inhibition, at this stage, has an antiremodeling effect, resulting in improved cardiac kinetics and circulating markers. This effect is independent of any other vasodilatory or endothelial effects and is apparently exerted through a direct intramyocardial action. Clinical Trial Registration—: URL: http://www.clinicaltrials.gov . Unique identifier: NCT00692237.