Henry Ford Hospital Medical Journal Volume 34 Number 3 Article 9 9-1986 Indications for Acute and Chronic Digitalis Administration in Heart Failure Mihai Gheorghiade Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Gheorghiade, Mihai (1986) "Indications for Acute and Chronic Digitalis Administration in Heart Failure," Henry Ford Hospital Medical Journal : Vol. 34 : No. 3 , 178-183. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol34/iss3/9 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Indications for Acute and Chronic Digitalis Administration in Heart Failure Mihai Gheorghiade, MD* lthough digitalis glycosides were introduced for the treat­ in patients having congestive heart failure in both the acute and Ament of cardiac disorders almost 200 years ago, doubt per­ convalescent phases of myocardial infarction yields conflicting sists regarding the role of these inotropic agents in the treatment and inconsistent data (14,15). of heart failure patients with a normal sinus rhythm. Cardiac If digitalis is administered to patients in sinus rhythm during glycosides are undoubtedly highly effective in controlling the the acute phase of myocardial infarction with either absent or ventricular response in the presence of atrial fibrilladon, and mild clinical heart failure, little hemodynamic benefit can be ex­ thereby enhance cardiac performance. Past experimental and pected (16,17). In contrast, digitalis therapy is of value in this clinical data have shown that various digitalis preparations im­ setting when atrial fibrillation is present; benefit is obtained by prove ventricular function when the dmg is acutely administered control ofthe ventricular response to the tachyanhythmia. Digi­ and indices of myocardial contractility are measured (1-3), How­ talis might be of benefit when signs of heart failure are accom­ ever, a dissociation may exist between the effects of digitalis on panied by an S3 gallop, significant cardiomegaly, and elevation indices of ventricular contractility (systolic time intervals, ofthe left ventricular end-diastolic pressure. However, even in measurements of rate of rise of left ventricular pressure, or di­ this setting, few studies in humans are available that suggest rect measurement of myocardial contractile force) and overall a significant improvement in left ventricular performance with cardiac pump performance, which is expressed as the rela­ digitalization (18). Fonesteret al (19), Lipp et al (20), and Gold­ tionship between left ventricular filling pressure and cardiac out­ stein et al (21) reported no occunence of hemodynamic im­ put. Although indices of contractility can be shown to increase provement in their patients, whereas Hodges et al (22) reported with acute administration of digitalis, significantly improved an improvement in only four of the ten patients studied. Rahim- pump performance does not always occur (4-7), toola et al (23) reported an improvement in left ventricular fill­ The clinical use of digitalis should be reexamined for several ing pressure without a significant change in cardiac index when reasons. Concerning the benefit of digitalis, the literature is ouabain was administered within 48 hours of acute myocardial somewhat confusing because authors fail to distinguish acute infarction. In fact, rapid intravenous administration of digi­ and chronic effects of the dmg. Scant information is available talis may be detrimental, which is perhaps related to its acute demonstrating the relative effect of cardiac glycosides compared peripheral constrictor effect (16). to the combination of diuretics and vasodilators in the treatment Infarct size—Varankov and associates (24) examined the of heart failure. A troubling risk of toxicity remains because of effect of acetylstrophanthidin on the rate of creatine phos- the nanow borderline between the therapeutic and toxic effects; phokinase (CK) efflux in 59 patients with acute myocardial in­ toxic manifestations of digitalis therapy still comprise some farction. They found an accelerated release of CK in the plasma of the most prevalent adverse drug reactions encountered in ofthese patients, with an evolving uncomplicated infarction, clinical practice (8). Except for the use of digitalis in atrial and concluded that digitalis administration may have adversely fibrillation, it is uncertain who benefits from digitalis. Cardiac increased infarct size. glycosides purportedly increase mortality when administered Arrhythmogenic effect—Whether patients with myocardial soon after myocardial infarction (9,10). In patients initially infarction are more sensitive to the arrhythmogenic effects of treated with diuretics to maintain dry body weight, no added digitalis has not been definitively ascertained. Reicansky and benefit from digitalis is observed (11). Newer inotropic drugs colleagues (25), using a double-blind randomized protocol, and vasodilators have been shown to be effective in treating found no difference in the incidence of rhythm disturbances be­ heart failure patients and may be superior to digitalis (12), tween digoxin-treated and control padents with acute myocar­ dial infarction. An increased susceptibility to anhythmias in the presence of digitalis intoxication has been observed in experi­ Acute Use of Cardiac Glycosides mental models following acute coronary ligation (26,27), Digitalis in acute myocardial infarction Although digitalis therapy in patients with acute myocardial Submitted for publication: July 31, 1986. Accepted for publication: August 21, 1986. infarction has been employed since 1912 (13), controversy per­ *Hearl and Vascular Institute, Division of Cardiovascular Medicine, Henry Ford sists regarding tbe indications and use of digitalis in such pa­ Hospital. Address correspondence to Dr Gheorghiade, Heart and Vascular Institute, Division of tients. Investigation ofthe effects of digitalis on cardiac function Cardiovascular Medicine, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, Ml 48202. 178 Henry Ford Hosp Med J—Vol 34, No 3, 1986 Digitalis and Heart Failure—Gheorghiade Therapeutic approach—Patients in sinus rhythm with mild to Table 1 moderate heart failure (bibasilar rales, S3 gallop, and upper Maintenance Diuretic and Vasodilator Therapy zone pulmonary venous redistribution on chest roentgenogram) Before and After Digoxin Withdrawal secondary to acute myocardial infarction should receive diuret­ ics alone or a combination of a diuretic and a vasodilator as the No. of Dose first step in their management. Intravenous nitroglycerin or Diuretics/Vasodilators Patients Mean (Range) nitropmsside appears to be highly effective in reducing the left Diuretics: Furosemide 12 55 mg (20 to 80 mg) ventricular end-diastolic pressure and improving cardiac output Hydrochlorothiazide 8 50 mg (25 to 100 mg) in such padents. The addition of digoxin to nitropmsside may Vasodilators: increase the cardiac output more than nitropmsside alone in pa­ Hydralazine 2 93 mg (40 to 200 mg) Isosorbide dinitrate 13 66 mg (40 to 120 mg) tients with heart failure complicating myocardial infarction, but Nitroglycerin ointment 3 2 in (2 to 4 in) it does not produce any further decrease in pulmonary capillary wedge pressure (28). Cardiogenic shock—The beneficial effects of digitalis have dynamic effects of digoxin discontinuation in patients with nor­ been examined in the setting of cardiogenic shock, in which mal sinus rhythm and congestive heart failure (36). We sought to marked hypotension is observed in association with an elevated determine changes not only in symptoms and physical findings left ventricular filling pressure. The prognosis of patients with after discontinuation of the dmg but also in left ventricular func­ cardiogenic shock appears to be unaltered following digitalis tion and exercise capacity. The major difference in our study de­ administration (17). Clinical studies have reported that the dmg sign from that employed in previous studies was to maximize does not appear to have any beneficial effect on left ventricular therapy with diuretics and vasodilator dmgs before discontinu­ function (29-31). Cohn and associates (29) demonstrated thatthe ing digoxin. early pressor effect of intravenously administered ouabain is deleterious in patients with cardiogenic shock. Digitalis adds lit­ Materials tle when compared with the more potent inotropic agents such as The study group patient population was homogeneous in that dobutamine (23). all had documented chronic heart failure secondary to coronary artery disease. Twenty-four consecutive patients were prospec­ tively studied. All 24 patients were men with a mean age of 60 Acute digitalization in patients with chronic heart failure years (range of 42 to 80 years). No patient had a history of atrial Not all padents with severe and chronic heart failure will tachyanhythmia. The indication for initiating long-term digoxin show an improvement in hemodynamics after the administration therapy in the study cohort was the presence of clinical and/or of intravenous digitalis (32-35). Selzerand Malmborg (32) were radiographic evidence of congestive heart failure. None of the unable to predict which patients would respond