Digitalis Toxicity Research Articles

Determination of digoxin serum level in patients with heart failure

Heart failure is one of the common cardiovascular diseases, and digoxin is required in the list of drug treatments. Considering the positive effect of this drug on heart failure, unfortunately, its therapeutic and toxic serum levels are different and very close to each other in different people. This study aimed to investigate the digoxin serum level in heart failure patients. For this purpose, we examined 32 patients with heart failure and digoxin users in this cross-sectional descriptive study. Some important factors involved in determining digoxin toxicity, such as age, gender, creatinine, creatinine clearance, cardiac output, urea, potassium, calcium, and digoxin levels, were measured. Statistical analysis showed that digoxin serum level increases with age (p<0.01). The increase in digoxin serum level was related to urea, creatinine, and potassium serum levels (p<0.01). In general, it seems that to prevent the increase of digoxin serum level and poisoning with it, it is necessary to continuously control the serum level of this drug in the form of serum measurement or according to its clearance.

Digoxina para fibrilação atrial: boa, mas não muito: relato de caso

Digoxin is a cardiotonic glycoside that is traditionally used for the treatment of heart failure and atrial fibrillation in humans and animals. However, the use of digoxin is still a challenge in clinical practice due to its narrow therapeutic range and its potential interaction with several drugs, which could facilitate the development of toxicity. A 12-year-old Labrador retriever was referred with a clinical diagnosis of heart failure and atrial fibrillation, anorexia, vomiting, and diarrhea. He had been medicated with digoxin, furosemide, lisinopril, and amiodarone. The patient also showed clinical signs of hip osteoarthritis and received firocoxib for four days. He additionally received drugs for gastrointeritis. The electrocardiogram demonstrated atrial fibrillation and signs of digitalis toxicity. Laboratory examination showed a high concentration of plasma digoxin, and 5 days after withdrawal of the drugs, the symptoms disappeared, as did the digitalis effects seen in the previous electrocardiogram.

Pentadecapeptide BPC 157 Counteracts Hemodynamic and ECG Disturbances Induced by Sotalol in Rats

Cytoprotective and organoprotective pentadecapeptide BPC 157 demonstrated particular beneficial cardiovascular effects (Curr Pharm Des. 2014;20(7):1121‐1125). Antiarrhythmic effects counteracted digoxin toxicity (Regul Pept. 2009;156(1‐3):83‐89), major blood vessel occlusions (Biomedicines 2021, 9,1029; 2021, 9,609; 2021, 9, 792) and lidocaine toxicity (Emerg Med Int. 2020;2020:6805354). Now, we reveal, by BPC 157, mitigation of hemodynamic and ECG disturbances of sotalol, a class III antiarrhythmic with non‐selective beta‐blocking activity.Albino Wistar rats received sotalol (80mg/kg, intragastrically), and at 5 min thereafter were treated with saline or BPC 157 (10ng/kg, intragastrically. Seven standard and one precordial ECG leads were recorded (baseline; after application of sotalol; and 10, 30, 90, 120 and 150 minutes after application of sotalol). Heart rate, QRS complex, PR and QT intervals were analyzed. Corrected QT intervals (QTc) were calculated according to Fridericia formula.Baseline ECG readings included average heart rate of 275.5 ± 25 bpm, average PR 54.8 ± 3.4 ms, average QRS complex 25.0 ± 4.23 ms and average QTc 166 ± 9.7 ms. Sotalol caused bradycardia (245 ± 23.5 bpm), PR prolongation (57.3 ± 2.7 ms), QRS widening (26.3 ± 3.2 ms), and QTc prolongation (173 ± 9.1 ms), measured 10 minutes after application. In BPC 157 treated animals (5 minutes after BPC‐157 application, 10 minutes after sotalol application), these effects were attenuated (heart rate 306 ± 31.7 bpm, average PR 52.3 ± 1.6 ms, average QRS 23.7 ± 5.4 ms and average QTc 159 ± 21.2 ms). This attenuation was lost in later measurements, for QRS ‐ 25 minutes after BPC 157 application, for frequency after 55 minutes, for PR after 115 minutes and for QTc after 145 minutes. In animals treated with sotalol, an increase in superior sagittal sinus pressure (10 ± 5 mmHg), as well as an increase in portal vein (17 ± 4 mmHg) and inferior caval vein pressures (12 ± 6 mmHg) were noted, along with the decrease in abdominal aortic pressure (53 ± 10 mmHg). These effects were attenuated in BPC treated animals (‐1 ± 1 mmHg for superior sagittal sinus, 7 ± 1 mmHg in portal vein, 5 ± 1 mmHg in inferior caval vein, and 81 ± 7 mmHg in abdominal aorta).In conclusion, BPC 157 attenuated deleterious hemodynamic effects of sotalol while the effects on the ECG parameters were also noted, although not long lasting, supporting the view of BPC‐157 as a rapid‐acting protective agent.

PO-657-05 AN UNCOMMON IDIOPATHIC ETIOLOGY OF BIDIRECTIONAL VENTRICULAR TACHYCARDIA

Bidirectional ventricular tachycardia (VT) is an uncommon arrhythmia which occurs most commonly in the setting of digoxin toxicity, catecholaminergic polymorphic VT, or Andersen-Tawil Syndrome. We present a case of bidirectional VT due to idiopathic premature ventricular complexes (PVCs) from two distinct foci treated with catheter ablation.

Evaluation of The Toxicity of Scorpion Venom and Digoxin on Human Cardiovascular System and in Decomposition Arthropods Succession Using Rat Carrions

Evaluation of The Toxicity of Scorpion Venom and Digoxin on Human Cardiovascular System and in Decomposition Arthropods Succession Using Rat Carrions

Serum digoxin concentrations in dogs with atrial fibrillation under long term digoxin treatment.

Background:Atrial fibrillation (AF) is the most common arrhythmia in dogs, most frequently diagnosed as chronic AF associated with a structural heart disease. The therapeutic strategy, in these cases, is based on the heart rate control and digoxin is one of the most used drugs.Aim:The aim of this work was to study the serum digoxin concentration changes in dogs with AF under long-term treatment with digoxin. Furthermore, the remission of clinical signs and the correlation between digoxinemia and other clinical and laboratory variables were retrospectively evaluated.Methods:The prospective study was conducted on seven large breed dogs from the time of reaching the definitive digoxin dosage. Digoxinemia was determined at month: 1, 3, 6, 9, 12, then twice a year. A post hoc statistical analysis investigated the influence of selected clinical and laboratory variables on the risk to develop spikes in digoxinemia. Clinical data, heart rate, digoxin dosage (mg/m2), and digoxinemia (ng/ml) at all available follow-ups were retrospectively evaluated from the medical records of 17 further dogs and a linear regression analysis was performed on the whole data set. The relation between the time of remission of AF clinical signs and variables was also investigated.Results:An unexpected increase in digoxin serum concentration was recorded in three dogs after one year monitoring, in absence of digoxin dosage changes. No statistical significance of all the studied variables on the risk to develop spikes of digoxinemia was registered. Two dogs, reaching digoxinemia 4.46 and 5.24 ng/ml, showed symptoms that reversed after digoxin withdrawal. From retrospective data, 88% of dogs reached complete reverse of AF clinical signs in 2.1 months from digoxin treatment starting, regardless of digoxin initial dosage, digoxinemia, and heart rate.Conclusion:Digoxin in monotherapy remain a good option to treat AF in dogs, anyway digoxin toxicity could emerge during long-term therapy, similarly to what happen in human medicine. Life-threatening spikes of digoxinemia could occur, especially after 1-year treatment with digoxin. It is very important that practitioners be aware of this possibility and encourage the owners to monitor digoxinemia during long-term treatment to avoid dangerous and toxic effects.

Predicting factors for the need of extracorporeal membrane oxygenation for suicide attempts by cardiac medication: a single-center cohort study.

Severe poisoning due to the overdosing of cardiac drugs can lead to cardiovascular failure. In order to decrease the mortality rate, the most severe patients should be transferred as quickly as possible to an extracorporeal membrane oxygenation (ECMO) center. However, the predictive factors showing the need for venous-arterial ECMO (VA-ECMO) had never been evaluated. A retrospective, descriptive, and single-center cohort study. All consecutive patients admitted in the largest ICU of Reunion Island (Indian Ocean) between January 2013 and September 2018 for beta-blockers (BB), calcium channel blockers (CCB), renin-angiotensin-aldosterone system blockers, digoxin or anti-arrythmic intentional poisonings were included. ECMO implementation was the primary outcome. A total of 49 consecutive admissions were included. Ten patients had ECMO, 39 patients did not have ECMO. Three patients in ECMO group died, while no patients in the conventional group died. The most relevant ECMO-associated factors were pulse pressure and heart rate at first medical contact and pulse pressure, heart rate, arterial lactate concentration, liver enzymes and left ventricular ejection fraction (LVEF) at ICU-admission. Only pulse pressure at first medical contact and LVEF were significant after logistic regression. A transfer to an ECMO center should be considered for a pulse pressure < 35 mmHg at first medical contact or LVEF < 20% on admission to ICU.

57 Using &lt;i&gt;in situ&lt;/i&gt; Simulation to Respond to Critical Incidents in Emergency Medicine

simulation (ISS) has been shown to be an effective tool in delivering education to the inter-professional team in the Emergency Department (ED) The aim of the study was o describe how simulation has improved learning and development from critical incidents.A simulated case is built around specific clinical incidents. Four were identified having occurred within the timeframe: missed abdominal aortic aneurysm, ischaemic limb, digoxin toxicity and ruptured ectopic pregnancy. The aim is to use ISS as a tool to educate colleagues about these presentations and as a way of checking that there are no system issues in managing such cases. Our ISS process involves either an ‘actor’ or a low-fidelity manikin with an ‘app’ providing a monitor. All equipment is sought and used in real time to attempt to simulate as close to real life as possible. The scenario utilizes junior doctors, nurses, healthcare assistants, trainee nurse associates and students. A senior team member is included if required. The participants are both briefed and debriefed, and learning points are disseminated via email placed on the ‘MYED’ Facebook group as well as the ‘MYEDSim’ ‘padlet’ page.The ISS was run between October 2020 and May 2021. A total of 23 participants answered the nine questions on the post-ISS feedback form from the four incidents. Results are summarized in Figure 1. The participants were asked to record learning points from the sessions and suggestions for improvement. Key themes appear to be communication, team working and location of equipment in the department.By running simulations of critical incidents, we have identified deficiencies in areas within individual’s knowledge, factors shaping inter-professional team working and system failings from the wider trust which contribute to these events. This has led to wide dissemination of learning and knowledge sharing on various departmental social media/communication platforms and has allowed development and modification of clinical guidance and pathways within Mid-Yorkshire NHS Trust to reduce risks of further incidents occurring.

A Study on the Prescription Pattern of Antimicrobial Agents Used in the Treatment of Infectious Disease

Antibiotics are anti-infective agents produced from natural sources, whereas antimicrobial agents are generated through chemical synthesis. It was a prospective and observational study and was conducted in the medicine, OBG, and urology departments in Sagar Hospitals. The study was conducted over a period of 18 to 20 months. Among 542 participants, 325 (60%) were males, while 217 (40%) were females. The frequency of patients surviving different hospital departments was 416 (76.6%), and they survived the medicine department. Moreover, the urology department had 80 (14.8%) patient visits, while in the obstetrics and gynaecology departments, only 46 (8.5%) patients visited. It was found that the percentage and order of various micro-organisms isolated as Neisseria meningitides 20 (3.7%) and a lesser number of organisms were found in K. Pneumonia 01 (0.2%), respectively. The cephalosporin class of drugs is commonly prescribed in empirical and prophylactic therapy because they are more effective in infectious diseases Furthermore, 36 patients out of 542 had drug interactions; quinoline derivatives, such as Ciprofloxacin, typically have a higher number of drug interactions. Among 542 patients, 38 had severe drug reactions in that most of the reactions were dermatological reactions caused by cephalosporin drugs. Most of our physicians prescribed based on patient characteristics and behaviors, and the recovery rate was also good. In our study, we observed common outcomes of DIs, such as increased theophylline toxicity and digoxin toxicity, increased laboratory values, and also reduced some drugs' effectiveness. Correlations of drug and disease characteristics were found more in ciprofloxacin drugs.

Utilization of Digoxin among Hospitalized Older Patients with Heart Failure and Atrial Fibrillation in Thailand: Prevalence, Associated Factors, and Clinical Outcomes.

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.

Digoxin’s Interactions with Various Drugs and A Case Report

Digoxin is a drug commonly used to achieve rate control in heart failure and atrial fibrillation with some form of arrhythmia. It shows a positive inotropic effect by inhibiting the Na + / K + ATPase pump in the myocardial cell membrane. Since digoxin is a drug with a narrow therapeutic range, the therapeutic dose range should be monitored and the individual dose regimen should be established, taking care of plasma concentrations. Factors such as patient's age, renal dysfunction, abnormal electrolyte values, drug-drug or drug-plant interactions increase the risk of intoxication. Patients may present with nausea and vomiting in digoxin intoxication and may present with ventricular arrhythmias with fatal rhythm disorders. Although digoxin should be discontinued as treatment, accompanying electrolyte imbalances should be treated. In patients with malignant arrhythmias, digoxin-specific antibodies should be considered in treatment. In this review, various drug-drug interactions that are frequently observed and easily prevented in patients taking digoxin are discussed with a case report.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

Updates in Digoxin Toxicity and Outcome of Management: A Review

Cardiac glycosides, including digitalis and digoxin, have long-standing use in clinical practice. Digoxin has a half-life that varies from 36 to 48 hours, which may increase in cases of renal failure. Approximately 1% of Congestive Heart Failure patients treated with digoxin develop toxicity. The clinical features of toxicity are often non-specific. Diagnosis is difficult and usually made clinically, as levels of digoxin in the blood do not necessarily correlate with toxicity. Treatment involves early recognition and the administration of antibodies specifically against digoxin also known as Fab fragments. Digoxin concentration does not necessarily correlate with clinical symptoms of toxicity however digoxin concentrations may be used for calculating the amount of antidote therapy. Digoxin-specific antibody fragments are used when there is a risk of a life-threatening arrhythmia.

Effect of Digoxin on the Color Vision Disorder, A Case-Control Study

Background and Aim: Digoxin is a drug commonly used in order to treat cardiac failure but its use has got different complications including color vision disorder .Regarding the high prevalence of cardiac failure and the role of taking this drug by patients, it was decided to study color vision disorder in patients who take digoxin.&#x0D; Materials and Methods: The present case-control study was conducted during 2008-2009 in Valli-e-asr hospital in Birjand.The case group consisted of 59 patients having cardiac failure who, at least, had taken oral digoxin for one year. The controls were non-cardiac patients referring to the hospital or were patients’ attendants who did not take digoxin. The controls were matched with the cases with respect to age and sex. Both groups were examined regarding whether they had color vision disorder or not by means of Ishiharatest. Venous blood was derived from all the cases to assess serum digoxin level.&#x0D; Then, the obtained data was an encoded and statistically analysed by means of SPSS software at the significant level α=0.05.&#x0D; Findings:In this survey, 59 patients with Heart failure who took digoxin and 59 controls were studied. Relative frequency of color vision disorder in the cases was estimated at 6.8%, but in the controls it was estimated at 1.7%; hence the difference was not statistically significant (P=0.36).Frequency of color vision disorder did not reveal a significant difference regarding age and sex. Serum digoxin level was abnormal in 5.1% of the patients. A significant difference was not found between mean serum digoxin and color vision disorder.&#x0D; Results:Using color vision disorder, as a diagnostic measure of Digoxin toxicity, is of no use.

A 5 Years Assessment of Patients with Acute Digoxin Poisoning

Background:Digoxin poisoning leads to the development of cardiac and noncardiac complications. Digoxin immune fab is a safe and effective antidote, but clinical trials have not been performed in this regard, and most of the evidence is based on prospective studies. Understanding the toxicoepidemiology pattern of digoxin poisoning could provide valuable context for better managing its acute poisoning.Objectives:This study aimed to assess the toxicoepidemiology pattern of acute digoxin poisoning through a 5-year assessment in Iran.Methodology:In this observational study, the records of 97 patients who were referred with acute digoxin poisoning between 2010 and 2015 were evaluated. Demographic characteristics, past medical history, drug history, chief complaints, vital signs, paraclinical findings, digoxin immune fab administration, and clinical outcomes recorded.Results:The mean age of patients was 34.02 ± 17.87 years old. About 24.7% of patients had underlying diseases, and among them, heart failure was the most prevalent disease (29.2%) 42.3% of patients needed intensive care unit (ICU) admission. The mean duration of ICU stay was 4.00 ± 2.29 days. Digoxin immune fab was administered for 4.1% of patients, and an average of 6.2 ± 2.2 vials were used for them. All patients survived, and no mortality was reported.Conclusions:Digoxin immune fab administration did not alter the mortality rate. Hence, it can be concluded digoxin immune fab is not appropriate in acute poisoning, but it may be considered in chronic poisoning. Furthermore, acute digoxin poisoning is more common in Iran, and it responds appropriately to conventional treatment.

Clinical experience with titrating doses of digoxin antibodies in acute digoxin poisoning. (ATOM-6)

Introduction For acute digoxin poisoning, it has been recommended to give bolus doses of 10–20 vials or potentially larger than needed doses calculated from dose ingested or the measured concentration. However, a recent revision of internal Poisons Information Centre guidelines prompted a change of our recommendations, specifically instead of large boluses, to use titrating repeated low doses of digoxin antibodies(Digoxin-Fab) based on bedside assessment of cardiac toxicity. Methods This is a prospective observational study of patients with acute digoxin poisoning identified through two Poisons Information Centres and three toxicology units. Patient demographics, signs and symptoms of digoxin toxicity, doses and response to Digoxin-Fab, free and bound serum digoxin concentrations. Outcomes were recorded and analysed. Results From September 2013 to September 2020, 23 patients with 25 presentations (median age 56 years, females 56%) were recruited. Median dose ingested was 13 mg(IQR: 9.5–25). Median heart rate (HR) was 41 beats/min before treatment. Initial median digoxin and potassium concentrations were 14.5 nmol/L (IQR: 10.9–20) [11.2 µg/L(IQR: 8.4–15.4)] and 5 mmol/L (IQR: 4.5–5.4 mmol/L), respectively. Gastrointestinal symptoms and acute kidney injury were present in 22 patients (88%) and 5 patients (20%), respectively. Four patients received an initial bolus dose of Digoxin-Fab of 5–20 vials. Twenty-one patients received repeated titrated doses (1–2 vials) of Digoxin-Fab and the median total dose was 4 vials (IQR: 2–7.5). Median maximal change in HR post-Digoxin-Fab was 19 beats/min. The median potassium concentration decrease post-Digoxin-Fab was 0.3 mmol/L. Total dose used in the titration group was 25% and 35% of the predicted doses based on the amount of digoxin ingested or measured serum concentration, respectively. Twelve had free digoxin concentrations measured. Free digoxin concentrations dropped to almost zero after any dose of Digoxin-Fab. Ten patients had a rebound of digoxin >2.6 nmol/L (2 µg/L). There were no deaths from acute digoxin toxicity. Conclusions The new practice of using small, titrated doses of Digoxin-Fab led to a considerable reduction in total usage and major savings. The clinical response to titrated doses was safe and acceptable in acute digoxin poisoning.

Utilizing Big Data to Identify Tiny Toxic Components: Digitalis.

The botanical genus Digitalis is equal parts colorful, toxic, and medicinal, and its bioactive compounds have a long history of therapeutic use. However, with an extremely narrow therapeutic range, even trace amounts of Digitalis can cause adverse effects. Using chemical methods, the United States Food and Drug Administration traced a 1997 case of Digitalis toxicity to a shipment of Plantago (a common ingredient in dietary supplements marketed to improve digestion) contaminated with Digitalis lanata. With increased accessibility to next generation sequencing technology, here we ask whether this case could have been cracked rapidly using shallow genome sequencing strategies (e.g., genome skims). Using a modified implementation of the Site Identification from Short Read Sequences (SISRS) bioinformatics pipeline with whole-genome sequence data, we generated over 2 M genus-level single nucleotide polymorphisms in addition to species-informative single nucleotide polymorphisms. We simulated dietary supplement contamination by spiking low quantities (0–10%) of Digitalis whole-genome sequence data into a background of commonly used ingredients in products marketed for “digestive cleansing” and reliably detected Digitalis at the genus level while also discriminating between Digitalis species. This work serves as a roadmap for the development of novel DNA-based assays to quickly and reliably detect the presence of toxic species such as Digitalis in food products or dietary supplements using genomic methods and highlights the power of harnessing the entire genome to identify botanical species.

B-PO04-219 COVID-19 ASSOCIATED BI-DIRECTIONAL VENTRICULAR TACHYCARDIA: DOUBLE WHAMMY

Bidirectional ventricular tachycardia (BiVT) is commonly associated with catecholaminergic polymorphic ventricular tachycardia (CPVT), digoxin toxicity, Anderson-Tawil syndrome, myocarditis, myocardial infarction, aconite poisoning, metastatic cardiac tumors, and certain cardiac channelopathies. Patients with coronavirus disease 2019 (COVID-19) who develop cardiac injury are at increased risk of malignant cardiac arrhythmias. However, BiVT in a setting of COVID-19 has not been reported.

Systematic treatment and prevention of cardiac digoxin toxicity

Digoxin has a narrow therapeutic index, such as complicated pharmacokinetics and dynamics. Many drug interactions may occur when the administration of one drug alters the clinical effects of another. As a result, digoxin toxicity can be a common condition within clinical settings that might lead to the development of many morbidities and even mortality. Many studies were published to investigate the efficacy and safety of different management modalities to enhance the outcomes that follow digoxin administration. The aim of the study was to discuss the approaches to systematically treat and prevent the development of cardiac digoxin toxicity. The findings are based on evidence from previous studies in the literature. To be specific, Fab fragments are the most effective modalities that can be used to treat severe cases within ideal periods. However, evidence regarding their administration for asymptomatic or mild cases is still poor regarding the cost-efficacy and the development of serious adverse events. Physicians should primarily care for a better intervention as it is usually associated with a significantly more enhanced prognosis and clinical outcomes. Nevertheless, adequate monitoring of the patients and evaluation of their personal and medical history are important steps in the process, and further approaches are still needed. Also, detailed information about our intended outcomes is furtherly discussed within the manuscript.

Predictive Factors for Recurrence of Serious Arrhythmias in Patients with Acute Digoxin Poisoning.

Although digoxin poisoning has declined in the past decades, it still has deleterious outcomes. The hallmark of serious life-threatening arrhythmias remains challenging due to its non-specific initial presentation. Therefore, this study aimed to evaluate the initial predictive factors for recurrent serious arrhythmias and the need for temporary pacing in acute digoxin-poisoned patients. This retrospective cohort study included all patients with acute digoxin poisoning admitted to Tanta University Poison Control Center from 2017 to 2020. Demographic and toxicological data, poisoning severity score (PSS), laboratory investigations, and serial ECG monitoring data were documented. Patients were divided according to their age into a childhood group and adolescence & adulthood group. Each age group was divided into two subgroups according to the presence of recurrent serious arrhythmias. Patient outcomes, including intensive care unit admission, temporary pacing, and in-hospital mortality were recorded. A percentage of 37.34% (n = 31) of the included patients had recurrent serious arrhythmias in both groups. Recurrent serious arrhythmias groups had significantly low heart rate, prolonged PR interval, high PSS, Mobitz II dysrhythmias, elevated serum digoxin, serum potassium and serum creatinine, and increased adverse outcomes compared to other groups. Logistic regression analysis showed that only serum digoxin and potassium levels were significant independent predictors of recurrent serious arrhythmias and temporary pacing. Serum digoxin level had an excellent discriminatory power with the best sensitivity and specificity, followed by serum potassium level in both groups. Thus, monitoring serum digoxin and potassium levels is essential in all patients with acute digoxin poisoning, especially with limited Fab availability.