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Digoxin and Mortality in Patients With Atrial Fibrillation Digoxin is widely used in patients with atrial fibrillation (AF).The goal of this paper was to explore whether digoxin use was independently associated with increased mortality in patients with AF and if the association was modified by heart failure and/or serum digoxin concentration.The association between digoxin use and mortality was assessed in 17,897 patients by using a propensity score-adjusted analysis and in new digoxin users (...) during the trial versus propensity score-matched control participants. The authors investigated the independent association between serum digoxin concentration and mortality after multivariable adjustment.At baseline, 5,824 (32.5%) patients were receiving digoxin. Baseline digoxin use was not associated with an increased risk of death (adjusted hazard ratio [HR]: 1.09; 95% confidence interval [CI]: 0.96 to 1.23; p = 0.19). However, patients with a serum digoxin concentration ≥1.2 ng/ml had a 56
Digoxin use and lower risk of 30-day all-cause readmission in older patients with heart failure and reduced ejection fraction receiving Î²-blockers. Digoxin use has been associated with a lower risk of 30-day all-cause admission and readmission in patients with heart failure and reduced ejection fraction (HFrEF).Digoxin use will be associated with improved outcomes in patients with HFrEF receiving β-blockers.Of the 3076 hospitalized Medicare beneficiaries with HFrEF (EF <45%), 1046 received (...) a discharge prescription for β-blockers, of which 634 were not on digoxin. Of the 634, 204 received a new discharge prescription for digoxin. Propensity scores for digoxin use, estimated for each of the 634 patients, were used to assemble a matched cohort of 167 pairs of patients receiving and not receiving digoxin, balanced on 30 baseline characteristics. Matched patients (n = 334) had a mean age of 74 years and were 46% female and 30% African American.30-day all-cause readmission occurred in 15% and 27
Mortality in heart failure with atrial fibrillation: role of digoxin and diuretics. The impact of atrial fibrillation (AF) on mortality of patients with heart failure (HF) has been established. Nevertheless, the effect of some factors in mortality, such as digoxin or diuretic use, remains controversial. This study aims at assessing mortality in community-dwelling patients with stable HF related to AF and determines the relation of these drugs with prognosis.Community-based cohort study of HF (...) ). At the end of the study, 25.8% patients had died, and mortality was higher when AF was present (28.8% vs 24.1%, P < 0.001, respectively). Multivariate model confirmed the higher risk of death for AF patients (HR 1.10 95%, CI 1.02-1.19). Digoxin and diuretics were not associated with higher mortality in AF patients (HR 1.04 95% CI 0.92-1.18 and HR 1.04 95% CI 0.85-1.26, respectively).An excess of mortality in HF patients with AF was found in a large retrospective community-based cohort. Digoxin
Toxicity , Digitalis Toxicity , Digibind , Digoxin-Immune Fab From Related Chapters II. Epidemiology Digoxin Toxicity was common with standard dose ( 7-20%) Lower doses used since in the U.S. has resulted in decreased toxicity III. Risk Factors Medication use interfering with excretion IV. Symptoms Yellow vision (xanthopsia) V. Signs VI. Labs Serum Level over 2.5 mg/ml Does not always correlate with toxicity Toxicity may occur at low levels and not at high ones Dysrhythmia Premature beats Bigeminy (...) (repeat as needed) Chronic toxicity: 3-6 vials for adults (1-2 for children) Adverse effects s (less common than with Digibind) Efficacy Only partial benefit in chronic toxicity (lowers level but does not correct or ) References Watts and Lovecchio (2016) Crit Dec Emerg Med 30(12): 24 Digibind (40 mg/vial) Replaced by DigiFab (due to fewer ) Indications Massive digoxin Refractory Digitalis Toxicity Calculate vials needed based on level Vials = ( Level in ng/ml) x (WtKg)/100 IX. References Orman
Treatment of fetal supraventricular tachycardia by intra-amniotic administration of digoxin. Fetal arrhythmias occur in as many as 1- 3% of pregnancies1 . Supraventricular tachycardia (SVT) accounts for about 66-90% of fetal tachyarrhythmia2 . First-line therapy has not been determined in randomized trials, but digoxin has been considered the first-choice drug. Flecainide and sotalol have been advocated as second-choice drugs, though flecainide might be more effective as a first-line treatment3
Party): Sahar Atef ALShabasy, Cairo University Study Details Study Description Go to Brief Summary: Digoxin is the primary cardiacglycoside in clinical use. Because of the narrow therapeutic index and risk of toxicity, therapeutic drug monitoring is highly recommended. In Egypt, most cardiologists give digoxin holiday for both atrial fibrillation and heart failure, it is not clear if the interrupted digoxin regimens are effective since serum digoxin concentrations might fall below the therapeutic (...) Description: Digoxin is a cardiacglycoside prescribed in heart failure and certain supraventricular tachyarrhythmias. It exerts a positive inotropic, neurohormonal, and electro physiologic actions on the heart . For heart failure patients, the targeted steady state serum digoxin level is between 0.5 and 0.8 ng/ml . Ventricular rate control in atrial fibrillation patients will usually require higher digoxin steady state serum concentrations . However, serum digoxin level higher than 2 ng/ml is associated
Elderly patients with suspected chronic digoxin toxicity: A comparison of clinical characteristics of patients receiving and not receiving digoxin-Fab. The aim of the present study was to compare clinical features of patients with elevated serum digoxin concentrations who were treated with digoxin-Fab with those where the immunotherapy was not given by a tertiary hospital toxicology service.This was a retrospective series of patients with supratherapeutic serum digoxin concentrations referred (...) to the toxicology service from August 2013 to October 2015. Data collected included demographics, presenting complaint, digoxin dose, other medications taken, serum digoxin, potassium and creatinine concentration on presentation and initial and post-digoxin-Fab heart rate.There were 47 referrals. Digoxin-Fab was administered in 21 cases. It was given more commonly when the heart rate was <51/min or serum potassium was >5.0 mmol/L. Patients receiving digoxin-Fab were more likely to be on maintenance therapy
04, 2017 Author: Vinod Patel, MD; Chief Editor: Jeffrey N Rottman, MD Share Email Print Feedback Close Sections Sections Digitalis Toxicity Overview Practice Essentials The incidence of digitalis toxicity has declined in recent years, due to decreased use along with improved technology for monitoring of drug levels and increased awareness of drug interactions. Nevertheless, cardiacglycoside toxicity continues to be a problem in the United States because of the wide use of digoxin (a preparation (...) of digitalis) and its narrow therapeutic window. It is important to learn about the source, amount, time of ingestion, presence of any coingestant, and patient’s own comorbidities. Acute digitalis toxicity can result from unintentional, suicidal, or homicidal overdose of the digitalis preparation digoxin, or accidental ingestion of plants that contain cardiacglycosides. Chronic toxicity in patients on digoxin therapy may result from deteriorating renal function, dehydration, electrolyte disturbances
Digoxin Use and Outcomes in Patients with Heart Failure with Reduced Ejection Fraction. Heart failure is a leading cause for hospital readmission. Digoxin use may lower this risk in patients with heart failure with reduced ejection fraction (HFrEF), but data on contemporary patients receiving other evidence-based therapies are lacking.Of the 11,900 patients with HFrEF (ejection fraction ≤45%) in Medicare-linked OPTIMIZE-HF, 8401 were not on digoxin, of whom 1571 received discharge prescriptions (...) for digoxin. We matched 1531 of these patients with 1531 not receiving digoxin by propensity scores for digoxin use. The matched cohort (n = 3062; mean age, 76 years; 44% women; 14% African American) was balanced on 52 baseline characteristics. We assembled a second matched cohort of 2850 patients after excluding those with estimated glomerular filtration rate <15 mL/min/1.73 m2 and heart rate <60 beats/min. Hazard ratios (HRs) and 95% confidence intervals (CIs) for digoxin-associated outcomes were
Prevalent digoxin use and subsequent risk of death or hospitalization in ambulatory heart failure patients with a reduced ejection fraction-Findings from the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) randomi Despite more than 200 years of clinical experience and a pivotal trial, recently published research has called into question the safety and efficacy of digoxin therapy in heart failure (HF).HF-ACTION (ClinicalTrials.gov Number: NCT00047437 (...) ) enrolled 2331 outpatients with HF and an EF ≤35% between April 2003 and February 2007 and randomized them to aerobic exercise training versus usual care. Patients were grouped according to prevalent digoxin status at baseline. The association between digoxin therapy and outcomes was assessed using Cox proportional hazard and inverse-probability weighted (IPW) regression models adjusted for demographics, medical history, medications, laboratory values, quality of life, and exercise parameters.The
Intravenous Amiodarone versus Digoxin in Atrial Fibrillation Rate Control; a Clinical Trial. Treatment of rapid ventricular response arterial fibrillation (rapid AF) varies depending on the decision of the in-charge physician, condition of the patient, availability of the drug, and the treatment protocol of the hospital. The present study was designed aiming to compare IV digoxin and amiodarone in controlling the heart rate of patients presenting to emergency department with rapid AF (...) and relative contraindication for first line drug in this regard.In the present clinical trial, patients presented to the ED with rapid AF and relative contraindication for calcium channel blockers and beta-blockers were treated with either IV amiodarone or IV digoxin and compared regarding success rate and complication using SPSS version 22. P < 0.05 was considered as statistically significant.84 patients were randomly allocated to either amiodarone or digoxin treatment groups of 42 (53.6% male). The mean
tachycardia. She was known to have congestive cardiac failure on diuretic therapy. Her serum digoxin level was within the normal range (2.4 nmol/L [normal = 1.9-2.6]) along with a normal serum potassium level (3.9 mmol/L [normal = 3.5-5]). However, there was severe hypomagnesemia (0.39 mmol/L [normal = 0.65-1.25]) precipitating digoxin-induced dysrhythmia, which responded well to intravenous magnesium therapy.This case reiterates that digoxin toxicity can occur in patients with normal digoxin (...) Digoxin Toxicity with Normal Digoxin and Serum Potassium Levels: Beware of Magnesium, the Hidden Malefactor. In recent years, digoxin use has been on the decline, with decreased incidence of digoxin toxicity. Hence, digoxin toxicity, when it occurs, remains an elusive diagnosis to emergency physicians.To present a case of digoxin toxicity with normal levels of digoxin and serum potassium, but with severe hypomagnesemia.A 66-year-old woman presented with junctional tachycardia and ectopic atrial
, caution is indicated when using binding resins concurrently with insulin/glucose/bicarbonate or digitalis Fab fragments, as the combination may precipitate hypokalemia, which may worsen clinical toxicity. Although calcium is often used to ameliorate cardiac toxicity from hyperkalemia, it is not recommended in patients with digoxin toxicity because it can delay after-depolarization and may precipitate ventricular tachycardia or fibrillation. This is based on the fact that intracellular calcium levels (...) supraventricular dysrhythmias induced by digitalis, whereas lidocaine has not been as effective. Lidocaine may be given in boluses of 100 mg, according to advanced cardiac life support (ACLS) guidelines. If this is successful, begin a maintenance infusion at 1-4 mg/min. Phenytoin has been administered in boluses of 100 mg every 5-10 minutes, up to a loading dose of 15 mg/kg. Atropine may be useful in blocking digoxin-induced effects of enhanced vagal tone on the sinoatrial (SA) and AV nodes. It has proved
Addition of beta-blockers to digoxin is associated with improved 1- and 10-year survival of patients hospitalized due to decompensated heart failure. Many of the studies associating digoxin use with increased mortality were conducted before beta-blockers became a standard therapy for heart failure (HF) patients. Our goal was to determine the effect of beta-blockers on the prognosis of patients hospitalized for decompensated HF who receive digoxin therapy at discharge.We analyzed 2402 patients (...) admitted with a primary diagnosis of decompensated HF during the prospective National Heart Failure Survey in Israel. Multivariate modeling was used to determine the effect of beta-blockers and digoxin on 1- and 10-year survival.Patients discharged on digoxin and beta-blockers (DIG+/BB+) had a lower 1-year mortality rate than those discharged on digoxin alone (DIG+/BB-), (31% vs. 44%; p<0.001). Digoxin administration was associated with an increase in adjusted 1-year (Hazard ratio [HR] 1.28; 95
The effect of 17α-ethynylestradiol induced intrahepatic cholestasis of pregnancy on placental P-glycoprotein in mice: Implications in the individualized transplacental digoxin treatment for fetal heart failure. Placental P-glycoprotein (P-gp) plays a significant role in controlling transplacental digoxin transfer rate. Investigations on P-gp regulation in placenta of women with different pregnant pathological states are of great significance to individualized transplacental digoxin treatment (...) cholestasis. Placental Abcb1a/Abcb1b/HIF-1α mRNA and P-gp/HIF-1α protein expression were determined by real-time quantitative PCR and western-blot. Maternal plasma and fetal-unit digoxin concentrations were detected by a commercial kit assay.The ICP group showed higher levels of maternal plasma ALT, AST, TB, DBIL, γ-GT, LDH, ALP and TBA concentrations, reduction in fetal survival rates, lower placental and fetal weights, and typical liver cells degeneration, necrosis and intrahepatic cholestasis
Digoxin Discontinuation and Outcomes in Patients With Heart Failure With Reduced Ejection Fraction. The deleterious effects of discontinuation of digoxin on outcomes in ambulatory patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF) receiving angiotensin-converting enzyme inhibitors are well-documented.The authors sought to determine the relationship between digoxin discontinuation and outcomes in hospitalized patients with HFrEF receiving more contemporary guideline (...) -directed medical therapies including beta-blockers and mineralocorticoid receptor antagonists.Of the 11,900 hospitalized patients with HFrEF (EF ≤45%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 3,499 received pre-admission digoxin, which was discontinued in 721 patients. Using propensity scores for digoxin discontinuation, estimated for each of the 3,499 patients, a matched cohort of 698 pairs of patients