Inappropriate use of digoxin in older hospitalized heart failure patients.

The most commonly used preparation of digitalis is digoxin, which is obtained from the leaves of Digitalis lanata , a common flowering plant called “foxglove.” The words digitalis and digoxin in this article are used interchangeably. An exhaustive review published in 19961 cited a large number of references and had detailed data and descriptions of a large number of studies and all early trials. The present article summarizes those data but focuses on and emphasizes data collected since that time. These have been described in detail previously1 and are briefly summarized. ### Inotropic Effects The inotropic effects have been documented in the isolated papillary muscles and in the normal hearts of animals and humans. The inotropic action occurs in both ventricles and in both atria. In the normal heart and in those with coronary artery disease and normal left ventricular (LV) systolic function, with digitalis the LV function curve is moved upward and to the left.1 As a result, LV end-diastolic pressure and LV end-diastolic and end-systolic volumes are reduced, and there is an increase of LV ejection fraction (LVEF).1 ### Patients With Heart Failure In patients with heart failure (HF), digoxin slows the ventricular rate (1) in sinus rhythm because of an improvement in HF and withdrawal of sympathetic stimulation and (2) in atrial fibrillation by increasing parasympathetic tone. The combination of digoxin and carvedilol is superior to digoxin or carvedilol alone.2 ### Peripheral Vessels In normal subjects given intravenous ouabain, there is arterial and venous vasocontriction.3 The vasoconstriction is obviated by administering digoxin slowly over a period of 15 to 20 minutes1; moreover, the vasoconstriction lasts up to 30 minutes. The seminal study of Mason and Braunwald3 showed that in HF, the effects are different. Digitalis produces an increase of blood flow, a decrease of vascular resistance, venodilation, and a …

Digitalis is the oldest compound in cardiovascular medicine that continues to be used in contemporary clinical practice.1 Evidence supporting the beneficial effects of digoxin on hemodynamic, neurohormonal, and electrophysiological parameters has been accumulated from >200 years of clinical experience and research (Table 1).2 View this table: TABLE 1. Effects of Digoxin Digoxin was approved for heart failure in 1998 under current regulations by the Food and Drug Administration on the basis of the Prospective Randomized Study of Ventricular Function and Efficacy of Digoxin (PROVED), Randomized Assessment of Digoxin on Inhibitors of the Angiotensin Converting Enzyme (RADIANCE), and Digitalis Investigators Group (DIG) clinical trials.3–5 It was also approved for the control of ventricular response rate for patients with atrial fibrillation. The most recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend digoxin for symptomatic chronic heart failure for patients with reduced systolic function (Class IIa recommendation: weight of evidence/opinion is in favor of usefulness/efficacy), preserved systolic function (Class IIb: usefulness/efficacy is less well established by evidence/opinion), and/or rate control for atrial fibrillation with a rapid ventricular response (Class IIa).6 The new Heart Failure Society of America guidelines for heart failure provide similar recommendations.7 Despite its relatively recent approval by the Food and Drug Administration and the guideline recommendations, digoxin use is decreasing in patients with heart failure.8 In the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) registry, only 30% of patients with left ventricular systolic dysfunction were being treated with digoxin before admission. Digoxin was added in only 8% of patients before discharge despite the fact that they had signs and symptoms of heart failure while receiving diuretics, ACE inhibitors, or angiotensin receptor blockers (ARBs) and β-blockers.9,10 This decrease in digoxin use is likely the result of several factors. …

Comparison of Afro-Caribbean Patients Presenting in Heart Failure With Normal Versus Poor Left Ventricular Systolic Function

His bundle pacing improves left ventricular diastolic function in patients with heart failure with preserved systolic function

Although inappropriate use of digoxin has been described in various populations, a real-world evaluation of patterns of digoxin prescription has not been well studied in patients with atrial fibrillation (AF). The aim of this study was to identify prevalence, indications and appropriateness of digoxin use in the general population of patients with non-valvular AF (NVAF) in Turkey. We included and classified patients from the RAMSES (ReAl-life Multicentre Survey Evaluating Stroke prevention strategies in Turkey) study, a prospective registry including 6273 patients with NVAF, on the basis of digoxin use. After excluding the data of 73 patients whose medical history about digoxin use or left ventricle function was absent, 6200 patients were included for the final analysis. Digoxin use was considered inappropriate if patients did not have left ventricular systolic dysfunction or symptomatic heart failure (HF). Digoxin was used in 1274 (20·5%) patients. Patients treated with digoxin were older (71·4 ± 9·8 years vs. 69·2 ± 10·9 years, P < 0·001), more likely to be female (58·8% vs. 55·9%, P = 0·019) and had more common comorbidities such as HF (40·2% vs. 17·4%), diabetes (26·4% vs. 21·1%), coronary artery disease (35·3 vs. 27·6%) and persistent/permanent AF (93·4% vs. 78·4%; P < 0·001 for each comparison). Of the 1274 patients, the indication of digoxin use was considered inappropriate in 762 (59·8%). Our findings show that nearly one-fifth of the patients with NVAF were on digoxin therapy and nearly 60% of these patients were receiving digoxin with inappropriate indications in a real-world setting.

The use of acid suppressive therapy (AST) in prevention of stress ulcers has been well defined in critical care patients, though its use has become increasingly common in general medicine patients, with little to no supportive evidence. None of the previous studies has examined the patient and physician characteristics of inappropriate AST initiation and use in hospitalized patients. The aim of our study was to identify: (1) the appropriateness of AST in hospitalized patients and the cost associated with inappropriate use; and (2) patient and physician characteristics predicting inappropriate initiation and use of AST. All discharges over a period of 8 consecutive days were selected. There were 207 patients discharged over a period of 8 days. AST was inappropriately initiated in 92 of 133 (69.2%) patients included in our study. On univariate analysis, higher hemoglobin value, postgraduate year 1 (PGY-1) residents, physicians with an MD degree, international medical graduates (IMGs), and internal medicine physicians were more likely to prescribe AST inappropriately. On multivariate analysis, a higher hemoglobin value, PGY-1 residents, and MD physicians were factors associated with inappropriate AST use. The total direct patient cost for this inappropriate use was $8026, with an estimated annual cost of approximately $366,000. AST was inappropriately initiated in 69.2% of patients with increased direct costs of $8026. Residents in their first year of training as well physicians with a MD degree are more likely to initiate AST inappropriately. Curtailing the inappropriate use of AST therapy may reduce overall costs for the patient and institution.

Dear Editor-in-Chief: While Ingle and Carroll suggest there are "methodological limitations" related to our study of elderly heart failure (HF) patients (4), we appear to arrive at similar conclusions, as they state in their recent manuscript (2) that "when an estimate of peak oxygen consumption (V˙O2peak) is required, incremental exercise testing with metabolic gas exchange measurements cannot be avoided." Specifically, Ingle and Carroll are concerned that we did not provide verbal "encouragement" during the 6-min walk test (6-MWT). We anticipated that over the course of this study, different personnel would administer the 6-MWT, and verbal "interaction" by different personnel would only add variability to our data collection. We did read a standardized script to each subject and controlled the environmental conditions and medication regimen on the day of testing. While verbal encouragement may have increased walking distance of each subject, the effect would have been consistent across all subjects and would not alter the relationships between the variables of interest. Ingle and Carroll also suggest that our "measures of exercise intolerance could be adversely affected by workload selection" and recommend using smaller workload increments (10-15 W·min−1). While there are several advantages to using a more linear "ramping" protocol, we chose a "staged" protocol to collect echocardiographic data during submaximal "steady-state" conditions. Our protocol, which increased the workload by 25 W every 3 min (i.e., 8.3 W·min−1), would likely yield a similar test duration to the protocol recommended. Ingle and Carroll also indicate that we may have excluded "more representative" elderly HF patients. As is the case with any clinical trial, we had specific inclusion and exclusion criteria; yet, "to evaluate the relationship between V˙O2peak and 6-MWT in older HF patients" (4), it was essential that all patients be able to adequately perform both the cardiopulmonary exercise test and the 6-MWT. In the original 6-MWT study in HF patients by Guyatt et al. (1), the exclusion criteria included "limitation of activity because of factors others than fatigue or exertional dyspnea, such as arthritis, claudication in the legs or angina." Furthermore, the mean V˙O2peak (13.5 mL·kg−1·min−1) of our subjects was well below values reported by Ingle et al. (2) and others and does not seem to indicate that we selected a "nonrepresentative" population of older HF patients for this investigation. While Ingle and Carroll indicate "6-MWT as a reproducible test in CHF with no changes in symptoms after 12 months" (3), we have recently presented (5) data on the relationships between changes in V˙O2peak and VT with 6-MWT in a randomized clinical trial of exercise training in older diastolic HF patients. Our results suggest that while the exercise-training group experienced an increase in 6-MWT and V˙O2peak, the control group had no change in V˙O2peak but did demonstrate a significant increase in the 6-MWT. Thus, our preliminary data challenge the validity of using 6-MWT as a serial measure of functional capacity in older HF patients. In closing, we agree with Ingle and Carroll that 6-MWT may be "the choice for assessing submaximal exercise tolerance in elderly CHF patients," but we stand by our conclusion that "direct measurements of V˙O2peak and VT should be preferred outcome measures when an accurate determination of functional capacity is required in elderly HF patients." Sara Maldonado-Martín0, PhD Faculty of Physical Activity and Sport Sciences University of the Basque Country Basque Country, Spain Peter H. Brubaker, PhD Wake Forest University Winston-Salem, NC

BackgroundDigoxin is used to control heart rate in patients with heart failure (HF) and atrial fibrillation (AF). However, its use is often limited in older patients, as they are prone to digoxin toxicity. This study aimed to determine the prevalence of digoxin use, investigate the factors associated with digoxin use, and explore the association between digoxin use and clinical outcomes in older Thai patients with HF and AF.MethodsThis cross-sectional study used data obtained from an electronic medical records database. We performed logistic regression analysis to determine the prevalence of digoxin use at index discharge and the factors associated with its use. The Cox proportional hazard model was used to determine the association of all-cause mortality and HF rehospitalization with digoxin use.ResultsOf the 640 patients assessed, 107 (16.72%) were prescribed digoxin before discharge. The factors negatively associated with digoxin use included high serum creatinine level (adjusted odds ratio [AOR]=0.38; 95% confidence interval [CI], 0.22–0.65) and ischemic heart disease (IHD) (AOR=0.52; 95% CI, 0.30–0.88). The factors positively associated with digoxin use were the use of diuretics (AOR=2.65; 95% CI, 1.60–4.38) and mineralocorticoid receptor antagonists (MRAs) (AOR=2.24; 95% CI, 1.18–4.27). We observed no significant association between digoxin use and clinical outcomes (adjusted hazard ratio=1.00; 95% CI, 0.77–1.30).ConclusionDigoxin use was prevalent among older patients with HF and AF. Patients with high serum creatinine or IHD were less likely to be prescribed digoxin, whereas those using diuretics or MRAs were more likely to be prescribed digoxin. Although digoxin use was not uncommon among older patients, it was prescribed with caution among Thai patients hospitalized with HF and AF.

We investigated the prevalence and indications of digoxin use in elderly patients presenting to a cardiology outpatient clinic of a tertiary hospital in Turkey. On a prospective basis, the study included 800 consecutive patients aged 70 or over (mean age 77 ± 6 years) who presented to our cardiology outpatient clinic. There were 124 patients (15.5%) receiving digoxin. All the patients underwent transthoracic echocardiography. Digoxin use was considered inappropriate if the patient had normal left ventricle systolic function or if there was no atrial fibrillation (AF). The reasons for use of long-term digoxin were persistent AF (n=55, 44.4%), heart failure (HF) (n=51, 41.1%), and paroxysmal AF (n=8, 6.5%). The exact reason could not be determined in 10 patients (8.1%). Digoxin use was based on appropriate indications in 76 patients (61.3%), whereas 48 patients (38.7%) were taking digoxin with inappropriate indications. Of 51 patients for whom HF was the only reason for digoxin therapy, diagnosis of HF was incorrect in 30 patients (24.2%). Other inappropriate indications were paroxysmal AF and undetermined indication for digoxin prescription. Concerning digoxin dose, 24 patients (19.4%) received one tablet (0.25 mg) and 30 patients (24.2%) received a half tablet (0.125 mg) on a daily basis, while 10 patients (8.1%) used six tablets per week with one day off (0.214 mg/day) and 60 patients (48.4%) took five tablets per week with two days off (0.179 mg/day). The median daily dose was 0.182 mg/day. Digoxin dose was higher than the recommended doses for elderly patients in 75.8% of the patients. Our findings show that nearly 40% of elderly patients receive digoxin with inappropriate indications and 75% of these patients take digoxin at higher doses than the recommended doses for this age group.

No abstract available.

To investigate the prevalence of digoxin use and appropriate and inappropriate indications for digoxin use in older patients at the time of admission to a nursing home. In a prospective study of 500 consecutive patients aged 60 years of age or older admitted to a nursing home, 96 (19%) patients were receiving digoxin at the time of admission to the nursing home. Appropriate and inappropriate indications for digoxin use were investigated in these 96 patients. A large, long-term health care facility where 500 consecutive older patients were studied. The 500 patients included 344 women and 156 men, mean age 81 +/- 8 years (range 60-100). Ninety-six of the 500 patients (19%) were receiving digoxin at the time of admission to the nursing home. Fifty-one (53%) of the 96 patients receiving digoxin had an appropriate indication for digoxin use, and 45 (47%) had an inappropriate indication for digoxin use. Appropriate indications for digoxin use included atrial fibrillation with or without congestive heart failure (CHF) in 35 patients (36%) and CHF with sinus rhythm and abnormal left ventricular (LV) ejection fraction in 16 patients (17%). Inappropriate indications for digoxin used included CHF with sinus rhythm and normal LV ejection fraction in 18 patients (19%), misdiagnosis of edema or dyspnea as CHF in patients with sinus rhythm and normal LV ejection function in 17 patients (18%), history of possible (undocumented) paroxysmal atrial fibrillation in nine patients (9%), and sinus tachycardia in one patient (1%). Two of the 45 patients (5%) inappropriately treated with digoxin had evidence of digitalis toxicity on their admission electrocardiogram. The prevalence of digoxin use was 19% in older patients at the time of admission to the nursing home. Almost half of patients (47%) receiving digoxin at the time of admission had an inappropriate indication for digoxin use at that time.

Digoxin and 30-day All-cause Hospital Admission in Older Patients with Chronic Diastolic Heart Failure

AimThis study aims to explore the risk factors for perioperative acute heart failure in older patients with hip fracture and establish a nomogram prediction model.MethodsThe present study was a retrospective study. From January 2020 to December 2021, patients who underwent surgical treatment for hip fracture at the Third Hospital of Hebei Medical University were included. Heart failure was confirmed by discharge diagnosis or medical records. The samples were randomly divided into modeling and validation cohorts in a ratio of 7:3. Relevant demographic and clinic data of patients were collected. IBM SPSS Statistics 26.0 performed univariate and multivariate logistic regression analysis, to obtain the risk factors of acute heart failure. The R software was used to construct the nomogram prediction model.ResultsA total of 751 older patients with hip fracture were enrolled in this study, of which 138 patients (18.37%, 138/751) developed acute heart failure. Heart failure was confirmed by discharge diagnosis or medical records. Respiratory disease (odd ratio 7.68; 95% confidence interval 3.82–15.43; value of P 0.001), history of heart disease (chronic heart failure excluded) (odd ratio 2.21, 95% confidence interval 1.18–4.12; value of P 0.010), ASA ≥ 3 (odd ratio 14.46, 95% confidence interval 7.78–26.87; value of P 0.001), and preoperative waiting time ≤ 2 days (odd ratio 3.32, 95% confidence interval 1.33–8.30; value of P 0.010) were independent risk factors of perioperative acute heart failure in older patients with hip fracture. The area under the curve (AUC) of the prediction model based on these factors was calculated to be 0.877 (95% confidence interval 0.836–0.918). The sensitivity and specificity were 82.8% and 80.9%, respectively, and the fitting degree of the model was good. In the internal validation group, the AUC was 0.910, and the 95% confidence interval was 0.869–0.950.ConclusionsSeveral risk factors are identified for acute heart failure in older patients, based on which pragmatic nomogram prediction model is developed, facilitating detection of patients at risk early.

Background: Digoxin has been used in older people for over 200 years to treat heart failure. Research over the past 15 years has caused the place of digoxin in therapy to evolve. This review was conducted in order to describe the role of digoxin in the care of older patients with heart failure. Methods: This review was conducted by systematically searching the literature using MEDLINE via Ovid, Cochrane Library, Pub Med and EMBASE, with the search terms “heart failure” and “digoxin.” Studies published after publication of the Digitalis Investigation Group (DIG) trial (conducted from February 1997 to October 2010) were selected for possible inclusion in the review. Results: The majority of data regarding the use of digoxin for heart failure in older people originates from the DIG trial and the various post-hoc analyses of this dataset. When considered in unison with evidence for other heart failure therapies (e.g., angiotensin-converting enzyme inhibitors), the place of digoxin is clear, in that it should be used for patients in sinus rhythm who are symptomatic despite therapy with first-line agents or for those with concomitant atrial fibrillation whose heart rate is not well controlled by, or cannot tolerate, beta-adrenergic blockers. There are various safety and monitoring parameters that should be considered in older people when using this drug. Conclusions: Digoxin is a drug that still demonstrates value for heart failure in older patients when used appropriately, and after first-line agents have been maximized.

Cardiovascular disease is ubiquitous within the elderly population and requires treatment with multiple types of medications. As with any cardiovascular pharmaceutical regimen, the risk versus the benefit of each medication must be strongly considered. This is particularly true where, for various reasons, adverse effects are more often prevalent and pronounced. Over the years, it has been documented that digoxin is a frequently prescribed medication in elderly populations. Although this drug can be beneficial when used in the appropriate setting, recent data would suggest that inappropriate administration of digoxin is common and not without potentially serious consequences. Currently, the use of digoxin can be advocated to control heart failure in atrial fibrillation and when added to ACE inhibitors and diuretics in those patients with symptomatic heart failure related to systolic left ventricular dysfunction. It is likely that the excessive use of digoxin in elderly populations as discussed in this review is perhaps based on the prevalence of diastolic heart failure in the elderly as well as other co-morbid conditions that may mimic heart failure signs and symptoms. Since the elderly appear to be at high risk for digoxin toxicity, the inappropriate use of this medication to treat these conditions could result in significant and unnecessary morbidity. It is proposed that echocardiography should be performed in most elderly patients when congestive heart failure is suspected. This simple diagnostic tool, along with a careful history and medical examination, would hopefully prevent the misinterpretation of confusing clinical findings and would help to identify the patients with normal systolic function or valvular disease such as critical aortic stenosis, where digoxin treatment would not be warranted. If it is necessary to administer digoxin, then the likelihood of significant toxicity can be greatly reduced by using an algorithm to calculate the appropriate dosage, which takes into consideration the patient's gender, bodyweight and creatinine clearance. Although it is probable that the indications for digoxin use to treat congestive heart failure will continue to evolve, at the present time most would recommend using this agent in symptomatic heart failure related to a reduction in left ventricular systolic function or when associated with atrial fibrillation.