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Principles of Heart Failure Pharmacotherapy
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Erika L. Hellenbart, Stephanie Dwyer Kaluzna, Robert J. DiDomenico
Digoxin is associated with several adverse effects. Digoxin can cause bradycardia and heart block, particularly in elderly patients and in those taking drugs known to interfere with SA or AV nodal conduction (e.g., beta-blockers, calcium channel blockers, or ivabradine) or enhance vagal tone (e.g., cholinesterase inhibitors). The narrow therapeutic range makes patients susceptible to digoxin toxicity, often in the setting of inappropriate dosing or WRF.78–80 Symptoms of digoxin toxicity may include anorexia, nausea, vomiting, and visual disturbances.78,79 In more serious cases, digoxin toxicity can cause complete heart block, hyperkalemia, and life-threatening ventricular arrhythmias.78,79
Medications
Published in Henry J. Woodford, Essential Geriatrics, 2022
Digoxin has been used in the management of atrial fibrillation (see page 389) and heart failure (see page 364). Although studies suggest only limited efficacy. Given the higher risk of toxicity in older people (see next section) and its potential anticholinergic effects, consideration should be given to discontinuation or switching to an alternative drug, such as a beta-blocker.
Congestive Heart Failure
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
Long-term management for HF is achieved with diuretics, nitrates, digoxin, ACE inhibitors, beta-blockers, aldosterone antagonists, ARBs, and angiotensin receptor/neprilysin inhibitors. If the sodium-glucose co-transporter 2 inhibitor called dapagliflozin is added, it can reduce complications and deaths if the patient has elevated natriuretic peptide levels. It has good effects in patients with diabetes mellitus or without. For arrhythmias, electrolytes are normalized, atrial and ventricular rates are controlled, and antiarrhythmic medications may be administered. For persistent sinus tachycardia, a beta-blocker given in increasing doses may be helpful. Atrial fibrillation with an uncontrolled ventricular rate is treated with a target resting rate being less than 80 beats per minute. Beta-blockers are used first, but rate-limiting calcium channel blockers are used with caution as long as systolic function is preserved. For some patients, digoxin is used to control heart rhythm or rate. A permanent pacemaker must be inserted for some patient.
Bibliometric profile of global scientific research on digoxin toxicity (1849–2015)
Published in Drug and Chemical Toxicology, 2020
Sa'ed H. Zyoud, William S. Waring, Samah W. Al-Jabi, Waleed M. Sweileh
Management is supportive, with steps taken to maintain normal hydration, consideration of intravenous calcium and magnesium, and close monitoring of serum electrolyte concentrations, including control of hyperkalaemia by administration of dextrose and insulin. Oral activated charcoal enhances elimination of digoxin (Ibanez et al. 1995, Fee 2004). Repeated doses every 1 to 4 hours should be considered, as this increases digoxin elimination by interfering with enterohepatic recirculation, although no evidence is available to determine if this improves clinical outcome (Lip et al. 1993). Digoxin-specific antibody fragments may be considered in patients with severe poisoning, including life-threatening ventricular arrhythmia, severe hyperkalaemia, or haemodynamic compromise (Smith et al. 1976, Wenger 1991, Critchley and Critchley 1997). The quantity of antibody is determined according to the dose of digoxin ingested, where known, or the serum digoxin concentration. Haemodialysis is of limited value in assisting elimination of digoxin due its wide distribution within tissues, but may be considered in patients with chronic kidney disease and severe hyperkalaemia (Mowry et al. 2016).
Recurrent lone atrial fibrillation in a twin pregnancy: a case report
Published in Journal of Obstetrics and Gynaecology, 2019
In 2011, the European Society of Cardiology (ESC) published guidance on the management of cardiovascular disease in pregnancy (Regitz-Zageosek et al. 2011). The ESC advises beta-blockers as a first line for rate control. Calcium-channel blockers and digoxin are recommended alternatives, however, serum digoxin measurements in pregnancy are unreliable. In this case, Bisoprolol was effective in converting the woman back to sinus rhythm. In a haemodynamically unstable patient, the ESC suggests electrical cardioversion. It has been shown that electrical cardioversion is safe up to 400 J for both mother and foetus at any gestation (Dicarlo-Meacham and Dahlke 2011). Although lone AF in pregnancy is highly unusual, it is important to be aware of the basic management as, if associated with a RVR rate, can result in significantly increased maternal and foetal mortality and morbidity.
Role of ivabradine and heart rate lowering in chronic heart failure: guideline update
Published in Expert Review of Cardiovascular Therapy, 2018
Sheryl L Chow, Robert L. Page, Christophe Depre
Beyond beta-blockade, current guideline-based management of HF does not support routine use of traditional heart rate lowering medications such as non-dihydropyridine calcium channel antagonists or digoxin in patients with reduced EF [9]. While both verapamil and diltiazem lower heart rate, their negative inotropic effects may further impair contractility and worsen HF. Therefore, these agents are contraindicated in the setting of reduced ejection fraction. Digoxin also lowers heart rate through vagomimetic activity and improves contractility by inhibiting the sodium/potassium ATPase and is still recommended in European guidelines as an option for patients who remain symptomatic despite standard of care [39]. However, more recent American guideline updates no longer support routine use of digoxin in such patients over concerns about risk of mortality associated with elevated digoxin serum concentrations [40,41]. Despite the removal of digoxin from current USA HF guidelines, use in select patients with concomitant atrial fibrillation might remain an option only after other therapies have been considered and if serum concentrations can be kept below 1.2 ng/mL. Based on these limitations, there has been an unmet need to identify other agents to reduce heart rate while minimizing major adverse effects.