digoxin and Bradycardia

Control of the heart rate (rate control) is central to atrial fibrillation management, even for patients who ultimately require control of the rhythm. We review heart rate control in patients with atrial fibrillation, including the rationale for the intervention, patient selection, and the treatments available. The choice of rate control depends on the symptoms and clinical characteristics of the patient, but for all patients with atrial fibrillation, rate control is part of the management. Choice of drugs is patient-dependent. β blockers, alone or in combination with digoxin, or non-dihydropyridine calcium-channel blockers (not in heart failure) effectively lower the heart rate. Digoxin is least effective, but a reasonable choice for physically inactive patients aged 80 years or older, in whom other treatments are ineffective or are contraindicated, and as an additional drug to other rate-controlling drugs, especially in heart failure when instituted cautiously. Atrioventricular node ablation with pacemaker insertion for rate control should be used as an approach of last resort but is also an option early in the management of patients with atrial fibrillation treated with cardiac resynchronisation therapy. However, catheter ablation of atrial fibrillation should be considered before atrioventricular node ablation. Although rate control is a top priority and one of the first management issues for all patients with atrial fibrillation, many issues remain.

Topics: Adrenergic beta-Antagonists; Age Factors; Amiodarone; Anti-Arrhythmia Agents; Atenolol; Atrial Fibrillation; Atrioventricular Node; Bradycardia; Calcium Channel Blockers; Cardiac Resynchronization Therapy; Catheter Ablation; Digoxin; Drug Therapy, Combination; Heart Failure; Heart Rate; Humans; Pacemaker, Artificial; Patient-Centered Care; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Sotalol

The objective of this review is to characterize the mechanisms, risk factors, and offending pharmacotherapeutic agents that may cause drug-induced arrhythmias in critically ill patients. PubMed, other databases, and citation review were used to identify relevant published literature. The authors independently selected studies based on relevance to the topic. Numerous drugs have the potential to cause drug-induced arrhythmias. Drugs commonly administered to critically ill patients are capable of precipitating arrhythmias and include antiarrhythmics, antianginals, antiemetics, gastrointestinal stimulants, antibacterials, narcotics, antipsychotics, inotropes, digoxin, anesthetic agents, bronchodilators, and drugs that cause electrolyte imbalances and bradyarrhythmias. Drug-induced arrhythmias are insidious but prevalent. Critically ill patients frequently experience drug-induced arrhythmias; however, enhanced appreciation for this adverse event has the potential to improve prevention, treatment, patient safety, and outcomes in this patient population.

Topics: Anesthetics, Inhalation; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Bradycardia; Bronchodilator Agents; Cardiotonic Agents; Critical Care; Digoxin; Drug-Related Side Effects and Adverse Reactions; Humans; Long QT Syndrome; Risk Factors; Torsades de Pointes; Water-Electrolyte Balance

Review bradycardia and medications that can cause the condition.

Topics: Adrenergic alpha-Antagonists; Adrenergic beta-Antagonists; Antidepressive Agents; Bradycardia; Calcium Channel Blockers; Cardiac Output; Digoxin; Drug Interactions; Histamine Antagonists; Humans; Lithium; Neuromuscular Blocking Agents

The cardiac effects of hypercalcaemia are usually manifest as a shortening of the QT-interval. Hypercalcaemia is infrequently associated with a clinically manifest arrhythmia. However, concomitant therapy with digoxin or underlying cardiac disease can potentiate the arrhythmogenic effects of hypercalcaemia, leading to a symptomatic rhythm disorder. We describe a symptomatic arrhythmia, which developed in a patient with hypercalcaemia secondary to squamous cell carcinoma of the bronchus. The patient was on digoxin therapy at the time. The arrhythmia did not recur after discontinuation of digoxin therapy and correction of the hypercalcaemia. Because of its effect on cardiac conduction, hypercalcaemia should be considered in the evaluation of any patient with an unexplained bradyarrhythmia. Conversely, patients with hypercalcaemia should discontinue digoxin therapy and be evaluated for the presence of rhythm disorders while receiving appropriate treatment for hypercalcaemia.

Topics: Aged; Aged, 80 and over; Anti-Arrhythmia Agents; Bradycardia; Bronchial Neoplasms; Carcinoma, Squamous Cell; Contraindications; Digoxin; Female; Humans; Hypercalcemia

Topics: Aged; Anti-Arrhythmia Agents; Arrhythmia, Sinus; Arrhythmias, Cardiac; Atrial Fibrillation; Atropine; Bradycardia; Digitalis Glycosides; Digoxin; Heart Block; Heart Ventricles; Humans; Infant; Isoproterenol; Lidocaine; Phenytoin; Potassium; Procainamide; Propranolol; Quinidine; Tachycardia; Tachycardia, Paroxysmal

Topics: Action Potentials; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Bradycardia; Digitalis Glycosides; Digoxin; Fever; Heart Atria; Heart Block; Humans; Hypotension; Lung Diseases, Obstructive; Methoxamine; Pacemaker, Artificial; Procainamide; Propranolol; Pulmonary Embolism; Quinidine; Tachycardia; Tachycardia, Paroxysmal; Ventricular Fibrillation

Topics: Arrhythmias, Cardiac; Bradycardia; Cardiac Complexes, Premature; Child; Child, Preschool; Deafness; Digoxin; Electric Countershock; Electrocardiography; Female; Heart Failure; Heart Ventricles; Humans; Infant; Infant, Newborn; Lidocaine; Male; Propranolol; Tachycardia; Ventricular Fibrillation; Wolff-Parkinson-White Syndrome

Topics: Acid-Base Equilibrium; Acidosis; Angiocardiography; Blood Gas Analysis; Blood Pressure; Bradycardia; Cardiac Catheterization; Cardiac Output; Child; Child, Preschool; Cineangiography; Cyanosis; Digoxin; Diuretics; Dyspnea; Electrocardiography; Heart Auscultation; Heart Block; Heart Defects, Congenital; Heart Failure; Heart Rate; Humans; Infant; Infant, Newborn; Oxygen Inhalation Therapy; Pulse; Referral and Consultation; Tachycardia; Vectorcardiography

A population of 283 patients with recent onset (< 72 hours) AF, without heart failure, who received a single 450- or 600-mg oral dose of propafenone, or digoxin 1 mg, or placebo for conversion to sinus rhythm (SR), was studied to determine whether a routine admission to the hospital for drug administration is justified. Previous bradyarrhythmias or sick sinus syndrome (SSS), and concomitant use of antiarrhythmic drugs were exclusion criteria. None of the 283 patients studied experienced VT or VF and none of them needed implantation of a temporary pacemaker. Periods of atrial tachyarrhythmias with regularization of atrial waves and 1:1 AV conduction were observed in only two cases, both receiving placebo. No predictor of proarrhythmia was found among the clinical variables considered (age, etiology, arrhythmia duration, atrial dimension, and blood potassium). No serious hemodynamic adverse effects were noted in either group. The rates of conversion to SR after 4 hours were: 80 (57%) of 141 patients who received propafenone and 35 (25%) of 142 patients who received digoxin or placebo (P < 0.001). Acute oral treatment with propafenone is simple and effective for the conversion of recent onset AF to SR in patients without clinical signs of heart failure. The routine admission of these patients to the hospital is not necessary. Home-based administration of oral propafenone to a selected group of patients could significantly increase the cost effectiveness of this treatment.

Topics: Administration, Oral; Age Factors; Anti-Arrhythmia Agents; Atrial Fibrillation; Atrial Function; Atrioventricular Node; Bradycardia; Cost-Benefit Analysis; Digoxin; Female; Forecasting; Heart Rate; Hemodynamics; Home Care Services; Humans; Male; Middle Aged; Pacemaker, Artificial; Patient Admission; Placebos; Potassium; Propafenone; Retrospective Studies; Sick Sinus Syndrome; Tachycardia; Tachycardia, Ventricular; Ventricular Fibrillation

1. The ideal drug treatment for atrial fibrillation will control resting heart rate, blunt exercise induced tachycardia whilst not exacerbating nocturnal bradycardia. Monotherapy with digoxin may not be ideal. We have compared the effect of combining digoxin (0.25 mg daily) with atenolol 50 mg and 100 mg or pindolol 5 mg twice daily and 15 mg twice daily in a cross-over randomised single-blind trial in eight symptomatic patients (six male; mean age 62 years) with poorly controlled atrial fibrillation. 2. Heart rate control was measured by 24 h ECG at baseline on digoxin therapy and after 2 weeks with each treatment. Symptom scores for breathlessness and palpitation were measured using visual analogue scales. 3. The addition of both beta-adrenoceptor blockers significantly reduced mean diurnal maximum heart rate from baseline (all P < 0.001 ANOVA). Atenolol at both doses caused a greater reduction than either dose of pindolol (P < 0.001 ANOVA). Nocturnal maximum heart rate was not significantly reduced from baseline by either beta-adrenoceptor blocker, but both doses of pindolol caused increases in nocturnal maximum heart rate compared with atenolol (P < 0.001 ANOVA). 4. Atenolol caused a reduction in diurnal minimum heart rate compared with baseline and caused a reduction in nocturnal minimum heart rate whereas pindolol caused an increase (P < 0.001 ANOVA). 5. Atenolol 100 mg caused longer nocturnal pauses compared with baseline but pindolol 15 mg twice daily reduced the number of nocturnal pauses > 1.5 s (P = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adrenergic beta-Antagonists; Aged; Analysis of Variance; Atenolol; Atrial Fibrillation; Bradycardia; Digoxin; Drug Synergism; Drug Therapy, Combination; Female; Heart Rate; Humans; Male; Middle Aged; Pindolol; Single-Blind Method

Topics: Aged; Benzazepines; Bradycardia; Clinical Trials as Topic; Coronary Disease; Digoxin; Diltiazem; Drug Therapy, Combination; Female; Heart Failure; Humans; Male; Placebos

Topics: Aged; Bradycardia; Clinical Trials as Topic; Digoxin; Female; Heart Diseases; Heart Valve Diseases; Humans; Hypertension; Male; Middle Aged; Myocardial Infarction; Pulmonary Edema; Pulmonary Heart Disease; Sclerosis

Bufo parotid glands and eggs contain cardiac glycosides also known as bufadienolides. This class of molecules can cause digoxin-like cardiac toxicity, as they can block the sodium potassium-adenosine triphosphatase (Na/K-ATPase) pump. Poisoning with these toxins is rare but carries a high mortality risk. There are only a few cases of toad poisoning that have been reported worldwide, mainly in the southern hemisphere. We will describe the case of a child on the autistic spectrum disorder who developed an acute and severe cardiac bradyarrhythmia soon after being in a mountain creek. The child ingested a large quantity of Bufo bufo toad eggs and developed bradycardia (35/min) associated with junctional rhythm with narrow QRS complexes. The poison control center (PCC) indicated the use of atropine on the way to the nearest hospital and the administration of antidotal therapy, i.e., anti-digoxine fragment antibodies (DigiFab), as soon as possible. The patient was transferred by air ambulance to the Regional Referral Pediatric Hospital (RRPH), tested for digoxin blood level by immuno-essay (0.68 ng/mL) and successfully treated with five vials of DigiFab, since atropine administration produced only a fleeting effect on the cardiac rhythm. Patient was discharged 48 hours after poisoning. The presence of bufadienolides in the toad eggs was also confirmed. To our knowledge, this is the first report of toad egg poisoning in Europe. The administration of Digifab helped to reverse the bufadienolide cardiac toxicity.

Topics: Animals; Atropine Derivatives; Bradycardia; Bufanolides; Bufo bufo; Bufonidae; Cardiotoxicity; Child; Digoxin; Eating; Humans; Sodium-Potassium-Exchanging ATPase

Warfarin is known to interact with many drugs and can lead to serious consequences. We report a case of 52 years old female patient from Himachal Pradesh. During hospital stay patient developed coagulopathy in form of INR above 10 and bradycardia with ventricular rate on ECG with digoxin level of 3.76 ng/ml. In this way digoxin toxicity was confirmed and it was considered as cause of coagulopathy after ruling out interactions of warfarin.

Topics: Bradycardia; Digoxin; Drug Interactions; Female; Humans; Middle Aged; Warfarin

We present a man undergoing regular haemodialysis sessions, who presented with non-specific symptoms of nausea, vomiting and light-headedness. He was found to have significantly raised serum digoxin concentrations, as well as a heart rate of 30 beats per minutes. An ECG showed complete heart block. He has a history of non-ischaemic dilated cardiomyopathy with resistant supraventricular and ventricular tachycardias and was on concomitant beta-blockade and digoxin. On questioning, he reported a gradual decline in his residual urine output over the past 6 months. He was reviewed by the cardiology team and required both pharmacological therapy for reversal of digoxin toxicity and temporary pacing in view of significant bradyarrhythmias. The beta-blockade and digoxin were discontinued. He was kept on continuous monitoring at the Cardiac Critical Care Unit. His symptoms resolved spontaneously once digoxin-specific antibody fragments were administered and temporary pacing successfully performed.

Topics: Aged; Anti-Arrhythmia Agents; Bradycardia; Cardiac Pacing, Artificial; Cardiomyopathy, Dilated; Digoxin; Drug-Related Side Effects and Adverse Reactions; Electrocardiography; Humans; Immunoglobulin Fab Fragments; Kidney Failure, Chronic; Male; Protective Agents; Renal Dialysis; Risk Adjustment; Tachycardia, Supraventricular; Treatment Outcome

Treatment of chronic digitalis intoxication includes suspension of drug intake, which may be sufficient in case of mild manifestations, and supportive measures. Severe bradycardia requires the administration of atropine or isoproterenol; placement of a temporary pacemaker may be required in case of absent response to pharmacological therapy. Severe and life-threatening manifestations should be treated with digoxin-specific fragment antigen binding antibodies (Fab). Therapeutic plasma exchange has been suggested, in addition to Fab therapy, to maximize the clearance of Fab-digoxin complexes in patients with renal failure. To date, few case reports have described the use of such a therapeutic approach; currently, extracorporeal methods are not recommended as part of the treatment of digitalis intoxication, and stronger evidence is required to establish their benefit.

Topics: Aged; Bradycardia; Digoxin; Female; Humans; Immunoglobulin Fab Fragments; Metabolic Clearance Rate; Plasma Exchange; Poisoning; Renal Insufficiency

Topics: Acute Kidney Injury; Aged, 80 and over; Amoxicillin; Anti-Arrhythmia Agents; Anti-Bacterial Agents; Atrial Fibrillation; Bradycardia; Bundle-Branch Block; Clarithromycin; Digoxin; Drug Interactions; Electrocardiography; Female; Helicobacter Infections; Helicobacter pylori; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Omeprazole; Tachycardia, Ventricular

We report a case of symptomatic bradycardia caused by consumption of a Chinese herbal medicine which was initially undisclosed to the attending emergency physician. The scientific name of the herb is Panax japonicus. Electrocardiogram revealed sinus bradycardia. Laboratory tests were normal except for the detection of a high serum digoxin level. Further interrogation of the patient eventually disclosed ingestion of the herb which, however, did not contain any digoxin. Other active ingredients in the herb include various types of ginsenoside. These are digoxin-like substances that had caused the observed false-positive detection of digoxin by fluorescence polarization immunoassay due to cross-reactivity. Our case-report provides an important insight about a blind-spot in the field of laboratory medicine (clinical pathology), namely, the false positive detection of digoxin due to crossreactivity in the immunoassay when we come across digoxin-like substances in clinical scenarios, which has barely received attention in the medical literature. It also conveys a clear educational message that with full understanding of the laboratory methodology and its mechanistic rationale there are actually some tricks-of-the-trade that allow us to optimize the specificity of the biochemical tests and the treatment of digoxin-like substances overdose.

Topics: Bradycardia; Cross Reactions; Digoxin; False Positive Reactions; Humans; Immunoassay; Male; Middle Aged; Panax

We hypothesized that in chronic digoxin toxicity, anti-digoxin antibodies (Fab) would be efficacious in binding digoxin, but this may not translate into improved clinical outcomes.. This study aims to investigate changes in free digoxin concentrations and clinical effects on heart rate and potassium concentrations in chronic digoxin poisoning when anti-digoxin Fab are given.. This is a prospective observational study. Patients were recruited if they have been treated with anti-digoxin Fab for chronic digoxin poisoning. Data was entered into a standardised prospective form, supplemented with medical records. Their serum or plasma was collected, analysed for free and bound digoxin and free anti-digoxin Fab concentrations.. From September 2013 to February 2015, 36 patients (median age, 78 years; 22 females) were recruited from 18 hospitals. Median heart rate (HR) was 49 beats/min. Initial median digoxin and potassium concentrations were 4.7 nmol/L (3.6 μg/L) (range: 2.3-11.2 nmol/L) and 5.3 mmol/L (range: 2.9-9.2 mmol/L) respectively. Beta-blockers (n = 18), calcium antagonists (n = 6), spironolactone and/or angiotensin blocking agents (n = 24) were also used concomitantly. Renal impairment and gastrointestinal symptoms were present in 31 (86%) and 22 (63%) patients respectively. Five patients died from conditions unrelated to digoxin toxicity. Median change in HR was 8 beats/min post-Fab with no effect on blood pressure; they were 4, 10 and 17 beats/min for the 1, 2 and ≥3 vials of anti-digoxin Fab groups respectively. Concomitant treatments with potassium lowering agents (12/36) and inotropic drugs (7/36) were used. Gastrointestinal effects resolved in all 22 patients. The median decrease for potassium was 0.3 mmol/L. Digoxin concentration reduced from 3.8 to 0 nmol/L post-Fab. There was a rebound observed in the free digoxin concentration in 25 patients but none had associated clinical deterioration.. One to two vials of anti-digoxin Fab initially bound all free digoxin confirming Fab efficacy. However, this was associated with only a moderate improvement in HR and potassium, suggesting bradyarrhythmia and hyperkalaemia may be from other co-morbidities.

Topics: Aged; Aged, 80 and over; Bradycardia; Cardiovascular Agents; Chronic Disease; Digoxin; Drug Overdose; Female; Heart Rate; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Male; Middle Aged; Poisoning; Potassium; Prospective Studies

A previously well woman aged 63 years presents to the emergency department with vomiting, palpitations and 3 presyncopal episodes. She had no previous medical or cardiac history, with the patient stating that she tried a herbal remedy of boiled comfrey leaves for insomnia 18 hours before arrival to the department. Her ECG showed multiple abnormalities, including bradycardia, second-degree atrioventricular node block, Mobitz Type 2, a shortened QT interval, downsloping ST depression and presence of U waves. After viewing the images of comfrey and foxglove, it highlighted the possibility of mistaken ingestion of Digitalis, containing the organic forms of cardiac glycosides, such as digoxin and digitoxin. Raised serum digoxin levels confirmed this. The patient was haemodynamically stable, and given digoxin-binding antibodies. After 5 days of cardiac monitoring, her ECG returned to normal rhythm, and she was discharged home.

Topics: Accidents; Antibodies, Heterophile; Atrioventricular Block; Bradycardia; Comfrey; Digitalis; Digoxin; Electrocardiography; Female; Humans; Middle Aged; Plant Leaves; Plant Poisoning; Plants, Medicinal; Sleep Initiation and Maintenance Disorders; Treatment Outcome; Vomiting

Topics: Acute Kidney Injury; Aged; Agglutinins; Anti-Arrhythmia Agents; Atrial Fibrillation; Bradycardia; Digoxin; Dosage Forms; Dose-Response Relationship, Drug; Drug-Related Side Effects and Adverse Reactions; Electrocardiography; Fatigue; Humans; Male; Treatment Outcome; Vision Disorders; Vomiting

Topics: Antidotes; Bradycardia; Chemistry Techniques, Analytical; Digoxin; Drug Overdose; Female; Humans; Immunoglobulin Fab Fragments; Middle Aged; Polyethylene Glycols

We hereby describe a case report of a 9-month-old girl, who was accidentally intoxicated with digoxin since her parents by mistake gave her digoxin instead of propranolol. At admission sinusbradycardia and a first-degree atrioventricular block was found and she was treated with antidigitalis Fab-fragment and atropine. After three days of hospitalization she was discharged well-being. We suspect that the explanation for this intoxication is due to confusion of bottles of magistral preparations of medicine, as they were very identical. Therefore we call for increased attention in children receiving this type of medicine.

Topics: Accidents, Home; Anti-Arrhythmia Agents; Bradycardia; Digoxin; Female; Humans; Infant; Tachycardia, Supraventricular

Topics: Acute Kidney Injury; Aged; Aged, 80 and over; Bradycardia; Cardiotonic Agents; Digoxin; Female; Humans; Takotsubo Cardiomyopathy

Topics: Aged, 80 and over; Anti-Arrhythmia Agents; Atrial Fibrillation; Bradycardia; Cardiac Pacing, Artificial; Digoxin; Female; Humans; Ventricular Fibrillation

Fetal supraventricular tachycardia (SVT) and atrial flutter (AF) can be associated with significant morbidity and mortality. Digoxin is often used as first-line therapy but can be ineffective and is poorly transferred to the fetus in the presence of fetal hydrops. As an alternative to digoxin monotherapy, we have been using sotalol at presentation in fetuses with SVT or AF with, or at risk of, developing hydrops to attempt to achieve more rapid control of the arrhythmia. The present study was a retrospective review of the clinical, echocardiographic, and electrocardiographic data from all pregnancies with fetal tachycardia diagnosed and managed at a single center from 2004 to 2008. Of 29 affected pregnancies, 21 (16 SVT and 5 AF) were treated with sotalol at presentation, with or without concurrent administration of digoxin. Of the 21, 11 (6 SVT and 5 AF) had resolution of the tachycardia within 5 days (median 1). Six others showed some response (less frequent tachycardia, rate slowing, resolution of hydrops) without complete conversion. In 1 fetus with a slow response, the mother chose pregnancy termination. The 5 survivors with a slow response were all difficult to treat postnatally, including 1 requiring radiofrequency ablation as a neonate. One fetus developed blocked atrial extrasystoles after 1 dose of sotalol and was prematurely delivered for fetal bradycardia. Three grossly hydropic fetuses with SVT showed no response and died within 1 to 3 days of treatment. In conclusion, transplacental sotalol, alone or combined with digoxin, is effective for the treatment of fetal SVT and AF, with an 85% complete or partial response rate in our series.

Topics: Abortion, Induced; Anti-Arrhythmia Agents; Atrial Flutter; Bradycardia; Catheter Ablation; Digoxin; Drug Therapy, Combination; Electrocardiography; Female; Fetal Death; Fetal Diseases; Humans; Hydrops Fetalis; Infant, Newborn; Live Birth; Pregnancy; Premature Birth; Retrospective Studies; Sotalol; Tachycardia, Supraventricular

In contrast to patients with acute digoxin overdose, the prognostic utility of the serum potassium concentration for patients with chronic digoxin toxicity is unclear. In such patients, we aimed to evaluate the relationship between pre-treatment serum potassium and survival.. This was a case-control study at an urban Poison Control Center affiliated with a large urban medical center. We compared the serum potassium concentration between patients with chronic digoxin toxicity resulting in fatality (cases) over a 7-year period (2000-2006) versus survivors (controls) over a 1-year period (2007-2008).. During the study period, there were 13 fatalities (cases) and 13 survivors (controls), of whom seven cases and five controls received appropriately dosed digoxin-specific antibody Fab fragments (Fab). There were no statistically significant differences between cases and controls with respect to serum digoxin concentration, creatinine, age, or sex. Serum potassium elevation pre-Fab was significantly associated with fatality both in mean difference (p < 0.03) and using a dichotomous cutoff of 5.0 mEq/L (p < 0.001), which performed with 92% sensitivity (95% CI 67, 99). In 86% of deaths despite appropriate Fab administration, the clinical presentation included the combination of bradycardia plus hyperkalemia.. In these patients with chronic digoxin toxicity, elevated serum potassium was associated with fatality. The combination of bradycardia and hyperkalemia strongly predicted fatality even in cases with appropriate Fab administration.

Topics: Aged; Aged, 80 and over; Bradycardia; Cardiotonic Agents; Case-Control Studies; Digoxin; Female; Humans; Hyperkalemia; Immunoglobulin Fab Fragments; Male; Potassium; Prognosis; Prospective Studies; Retrospective Studies; Sensitivity and Specificity; Urban Health Services

Topics: Adrenergic beta-Antagonists; Aged; Amiodarone; Atrial Fibrillation; Bisoprolol; Bradycardia; Calcium Channel Blockers; Cardiovascular Agents; Combined Modality Therapy; Digoxin; Diltiazem; Female; Humans; Hypothyroidism; Kidney Failure, Chronic; Myocardial Infarction; Pacemaker, Artificial; Renal Dialysis

Topics: Atrial Fibrillation; Bradycardia; Burns; Digoxin; Electrocardiography; Follow-Up Studies; Heart Rate; Humans; Injections, Intravenous; Male; Metoclopramide; Middle Aged; Tachycardia, Paroxysmal

We report a case of digoxin-like toxicity because of ingestion of foraged plants. This patient presented with nausea, vomiting, bradycardia, and hypotension after ingesting Veratrum viride (false hellebore). The patient's serum specimen demonstrated a positive digoxin level (0.38 ng/mL) measured by a clinical tubidimetric immunoassay. We hypothesize that steroidal alkaloid compounds contained in V. viride cross-react with the Multigent Digoxin immunoassay reagent antibodies.. Plant extracts from V. viride demonstrated cross-reactivity to Multigent reagent antibodies but did not bind therapeutic DigiFab antibodies. Gas chromatography/mass spectrometry analyses identified several steroidal alkaloid compounds present in the V. viride extracts: jervine, ribigirvine, solanidine, and veratraman.. This study indicates that compounds extracted from V. viride can cross-react with a clinical Digoxin immunoassay. Yet these extracts did not bind DigiFab antibody fragments used for therapeutic intervention. Providers should not unnecessarily administer DigiFab fragments as an antidote in symptomatic V. viride toxic patients.

Topics: Biological Assay; Bradycardia; Chemistry, Clinical; Cross Reactions; Digoxin; Eating; Humans; Hypotension; Immunoassay; Immunoglobulin Fab Fragments; Nausea; Plant Extracts; Plants; Veratrum; Veratrum Alkaloids; Vomiting

Topics: Adult; Atrioventricular Block; Bradycardia; Comfrey; Digitalis; Digoxin; Dizziness; Electrocardiography; Humans; Male; Nausea; Phytotherapy; Plant Leaves; Vision Disorders; Vomiting

Topics: Aged, 80 and over; Bradycardia; Cardiotonic Agents; Confusion; Digoxin; Electrocardiography; Female; Humans

We report here the successful treatment of a 16-year-old female who ingested 20 tablets of digoxin each containing 0.25 mg (total dose ingested equivalent to 0.1 mg/kg), 32 tablets of warfarin each containing 5mg (equivalent to 3.2 mg/kg), and approximately 15 tablets of propafenone each containing 300 mg (equivalent to 90 mg/kg). The patient developed hypotension and sinus bradycardia necessitating external cardiac pacing 17 hours after drug ingestion. In addition to gastric lavage, activated charcoal, blood alkalinisation, administration of vitamin K and temporary cardiac pacing, the authors performed plasma exchange for drug removal and administered rifampicin in order to increase the metabolism of digoxin, propafenone and warfarin. The patient was discharged without any sequelae. Plasma exchange may be lifesaving in drug ingestions where there is a low volume of distribution and high plasma protein binding. Rifampicin, an inducer of cytochrome p450, may be used in intoxications for elimination of drugs with inactive metabolites.

Topics: Adolescent; Anti-Arrhythmia Agents; Anticoagulants; Bradycardia; Cytochrome P-450 Enzyme System; Digoxin; Drug Overdose; Enzyme Induction; Female; Humans; Hypotension; Plasma Exchange; Propafenone; Rifampin; Warfarin

Topics: Anti-Arrhythmia Agents; Atrial Fibrillation; Bradycardia; Digoxin; Drug Interactions; Electrocardiography; Female; Humans; Hypotension; Middle Aged; Sotalol; Time Factors; Verapamil

The indications of digoxin therapy has been significantly narrowed and also the effective target therapeutic blood level has been decreased (0.9 micromol/L) compared to the previously desired one.. In this retrospective trial the data of 60 consecutive patients over 65 years (25 male, 35 female, mean age 77.3 +/- 5.0 y), hospitalized between 01. 01. 2002 and 31. 12. 2003 with a diagnosis of chronic heart failure and elevated (> 1.2 microg/I) serum level of digoxin, were analyzed.. Beside the analysis of the age, sex, serum level of digoxin and potassium, creatinine clearance value, symptoms and ECG-signs of digitalis intoxication, presence of atrial fibrillation, concomitant diseases and left ventricular ejection fraction value, the reasonability of digitalis treatment and therapy applied at the time of discharge (considering actual treatment guidelines) were also reviewed.. At the admission mean serum level of digoxin was 2.1 +/- 0.9 microg/l. 20 patient's value (33.3%) was found above 2.2 microg/l. Symptoms characteristic for digitalis intoxication were observed in 28 patients. On the ECG performed at admission signs of digitalis effect/overdose were observed in 54 cases ("bigemin" ventricular extrasystoles, bradycardia, characteristic down-sloping ST-depressions). The mean left ventricular ejection fraction of the patients (51.5 +/- 12.7%) did not suggest to a significant left ventricular systolic dysfunction. For the elevated serum level of digoxin the impaired renal function (mean creatinine clearance 42.9 +/- 21.3 mL/min) was responsible in most cases. In patients with the highest serum level of digoxin (n = 20, 3.2 +/- 0.7 microg/L) the creatinine clearance was even lower, 30.4 +/- 13.7 mL/min. During hospital treatment the administration of digitalis was found to be unnecessary and thus terminated in 44 patients. At the discharge only 16 patients were receiving digitalis, 14 of them digoxin and 2 patients digitoxin.. The authors emphasize, that in case of elderly patients the indication and control of digitalis therapy requires greater precaution and tight doctor-patient cooperation.

Topics: Aged; Aged, 80 and over; Atrial Fibrillation; Bradycardia; Cardiotonic Agents; Creatinine; Digoxin; Drug Prescriptions; Electrocardiography; Female; Heart Failure; Humans; Hungary; Male; Patient Admission; Patient Discharge; Potassium; Retrospective Studies; Stroke Volume; Ventricular Premature Complexes

Acute digitalis overdosage is characterized by high electric instability, its mortality may reach 10-15 percent even nowadays.. To detect the possible risk factors which might predict severe intoxication.. Data of 50 patients treated at authors' department with acute digoxin poisoning over the past 8 years could be retrospectively evaluated. Cases were classified according to the Poison Severity Score (PSS). The following parameters were taken into consideration: age, sex, diseases influencing the severity of intoxication, dose of the drug, heart frequency, serum potassium and digoxin levels and vomiting. For statistical analysis a Kruskal-Wallis test and a chance-quotient calculation was applied.. From 50 patients 30 were mild (PSS 1, 2), 20 were severely poisoned, which subgroup included 8 deaths (PSS 4) and 12 patients who recovered (PSS 3). Based on Kruskal-Wallis test significant differences were found in the following items: greater number of primary diseases PSS 4 vs other subgroups (p < 0.05); bradycardia PSS 4 vs PSS 2 (p < 0.05) and PSS 3 vs PSS 2 (p < 0.05); hyperkalaemia PSS 3 vs PSS 2 (p < 0.01); elevated serum digoxin level PSS 3 vs PSS 2 (p < 0.05). The risk of severe poisoning (PSS 3-4) was increased in case of hyperkalaemia, bradycardia, vomiting (p < 0.001), and if the patients' age and if the drug dose exceeded 65 years or 10 mg, respectively (p < 0.05).. The predictive risk factors concerning severe acute digoxin poisoning are profuse vomiting, hyperkalaemia and bradycardia. The predictive risk factors of fatal outcome are age over 65 years associated with primary disease, vomiting and bradycardia.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Bradycardia; Cardiotonic Agents; Digoxin; Female; Heart Rate; Humans; Hyperkalemia; Male; Middle Aged; Poisoning; Predictive Value of Tests; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Vomiting

A chronically depressed 44-year-old man was rescued by the French medicalised ambulance service four hours after the ingestion of Nerium oleander leaves in a suicide attempt. Cardiotoxicity was evidenced by the presence of bradycardia with mental confusion and vomiting. The patient was empirically treated in the prehospital phase with a single dose of digoxin-specific Fab antibody fragments (Digidot). In spite of this treatment, the patient presented a new episode of important bradycardia (25 b/minute). Thereafter, the patient's rhythm stabilized and neurological signs and vomiting resolved. The patient recovered uneventfully and was discharged from the intensive care unit two days later.

Topics: Adult; Antibodies, Blocking; Bradycardia; Digoxin; Emergency Medical Services; Heart Diseases; Humans; Immunoglobulin Fab Fragments; Male; Nerium; Suicide, Attempted; Vomiting

Topics: Bradycardia; Diagnosis, Differential; Digitalis; Digitoxin; Digoxin; Electrocardiography; Female; Humans; Middle Aged; Nausea; Plant Poisoning; Syncope; Vomiting

Patients with digoxin intoxication may need transvenous temporary cardiac pacing (TCP) when symptomatic bradyarrhythmias are present. However, it has been reported that TCP might be associated with fatal arrhythmias in patients with acute digitalis intoxication caused by attempted suicide. The aim of this study was to assess the safety of TCP in patients with accidental digoxin-related symptomatic bradyarrhythmias.. Seventy patients (30 men; age 74 +/- 12 years) were enrolled in this retrospective study. Patients were divided into two groups: group 1 with TCP and group 2 without TCP. A digoxin overdose was defined as a serum digoxin level higher than 2.0 ng/ml combined with the presence of digoxin-related symptoms. Detailed clinical characteristics were reviewed on the basis of the medical records.. Group 1 included 24 patients (34.3%, 10 men). The rhythms prior to pacemaker insertion in group 1 included sinus arrest with junctional bradyarrhythmias (n = 9), atrial fibrillation with a slow ventricular rate (n = 11), and high-degree atrioventricular block (n = 4). The mean duration of pacemaker implantation was 5.8 +/- 2.9 days (2-12 days). There was no major arrhythmic event or mortality after TCP in group 1. Two patients in group 2 (4%) died of ventricular tachyarrhythmias. Group 1 had a higher level of blood urea nitrogen (45.1 +/- 26.0 vs. 33.4 +/- 19.3 mg/dl), of left ventricular ejection fraction (68 vs. 56%), and of digoxin (4.4 +/- 2.1 vs. 3.4 +/- 1.3 ng/ml) but a lower serum calcium level (8.7 +/- 0.6 vs. 9.1 +/- 0.8 mg/dl).. TCP was safe for patients with a digoxin overdose complicated by symptomatic bradycardia and should be recommended in such situations. However, this conclusion does not apply to acute digoxin intoxication as a result of attempted suicide.

Topics: Aged; Aged, 80 and over; Bradycardia; Cardiac Pacing, Artificial; Digoxin; Drug Overdose; Female; Humans; Male; Middle Aged; Retrospective Studies; Treatment Outcome

We describe a case of unintentional poisoning from a cardioactive steroid and the subsequent analytic investigation. A 36-year-old woman with no past medical history and taking no conventional medications ingested an herbal preparation marketed for "internal cleansing." Its ingredients were neither known to the patient nor listed on the accompanying literature. The next morning, nausea, vomiting, and weakness developed. In the emergency department, her blood pressure was 110/60 mm Hg, and her pulse rate was 30 beats/min. Her ECG revealed a junctional rhythm at a rate of 30 beats/min and a digitalis effect on the ST segments. After empiric therapy with 10 vials of digoxin-specific Fab (Digibind), her symptoms resolved, and she reverted to a sinus rhythm at a rate of 68 beats/min. Her serum digoxin concentration measured by means of the fluorescence polarization immunoassay (Abbott TDx) was 1.7 ng/mL. Further serum analysis with the Tina Quant digoxin assay, a more digoxin-specific immunoassay, found a concentration of 0.34 ng/mL, and an enzyme immunoassay for digitoxin revealed a concentration of 20 ng/mL (therapeutic range 10 to 30 ng/mL). Serum analysis by means of high-performance liquid chromatography revealed the presence of active digitoxin metabolites; the parent compound was not present. When the diagnosis of cardioactive steroid poisoning is suspected clinically, laboratory analysis can confirm the presence of cardioactive steroids by using immunoassays of varying specificity. An empiric dose of 10 vials of digoxin-specific Fab might be beneficial in patients poisoned with an unknown cardioactive steroid.

Topics: Adult; Bradycardia; Cardiac Glycosides; Dietary Supplements; Digoxin; Electrocardiography; Female; Humans; Hypokalemia; Immunoglobulin Fab Fragments; Muscle Weakness; Nausea; Plant Preparations; Treatment Outcome; Vomiting

A healthy man developed gastrointestinal symptoms after ingesting purported aphrodisiac pills. He had severe unrelenting bradycardia, hyperkalaemia, and acidosis. He rapidly developed severe life threatening cardiac arrhythmias and died after a few hours. He was found to have positive serum digoxin concentrations, although he was not taking digoxin. Toad venom poisoning is similar to digitalis toxicity and carries a high mortality. Cardiac glycoside poisoning can occur from ingestion of various plants and animal toxins, and the venom gland of cane toad (Bufo marinus) contains large quantities of cardiac glycosides. Toad venom, a constituent of an aphrodisiac, was considered responsible for the development of clinical manifestations and death in this patient. Digoxin specific Fab fragment has been reported to be beneficial in the treatment of toad venom poisoning. This report alerts physicians to the need to be aware of a new community toxic exposure, as prompt treatment with digoxin specific Fab fragment may be life saving. The treatment approach to patients with suspected toad venom poisoning is described.

Topics: Adult; Amphibian Venoms; Animals; Anura; Aphrodisiacs; Bradycardia; Diagnosis, Differential; Digoxin; Fatal Outcome; Humans; Male; Plant Poisoning

To describe the development of bradycardia during sedation with dexmedetomidine in a patient concurrently receiving digoxin.. Case report.. The pediatric intensive care unit of a tertiary care children's hospital.. A 5-wk-old infant with an atrioventricular septal defect requiring sedation during mechanical ventilation for acute respiratory syncytial virus infection.. As part of an ongoing evaluation of dexmedetomidine for sedation in the pediatric intensive care unit, the patient received a loading dose (0.5 microg/kg) followed by an infusion (0.44 microg x kg(-1) x hr(-1)) of dexmedetomidine. Sedation assessments and hemodynamic data were collected at least every 2 hrs. During the loading dose, the patient's heart rate decreased from 133 beats/min per min to 116 beats/min. During the ensuing 13 hrs, the heart rate continued to decrease into the mid 90s, with additional episodes of bradycardia into the 40s and 50s. Within 1 hr of discontinuation of the dexmedetomidine infusion, the baseline heart rate had recovered, and no further episodes of acute bradycardia were noted.. This case adds to the limited data regarding dexmedetomidine in pediatric critical care and suggests that caution should be used when considering sedation with dexmedetomidine in patients also receiving digoxin.

Topics: Adrenergic alpha-Agonists; Bradycardia; Cardiotonic Agents; Dexmedetomidine; Digoxin; Drug Interactions; Female; Humans; Infant

Atrioventricular (AV) dissociation is an electrocardiographic syndrome; a descriptive term for a variety of conditions of abnormal cardiac conduction which all feature independent function of the atria and ventricles. AV dissociation can be subclassified as AV dissociation by default (an independent ventricular pacemaker responds to slowing of the dominant atrial pacemaker) versus AV dissociation by usurpation (acceleration of a latent pacemaker takes control of cardiac conduction by exceeding the intrinsic atrial rate). Inclusion of third degree AV block (complete heart block) as a manifestation of AV dissociation is controversial, yet is functionally appealing in that this disorder also features independent activity of the atria and ventricles.

Topics: Aged; Arrhythmias, Cardiac; Bradycardia; Calcium Channel Blockers; Coronary Disease; Diagnosis, Differential; Digoxin; Electrocardiography; Emergencies; Female; Heart Atria; Heart Block; Heart Ventricles; Humans; Male; Middle Aged; Sinoatrial Node; Suicide; Tachycardia, Ventricular

Herbal dietary supplements are often considered by patients to be safe and free from side effects. The case described here shows digoxin toxicity in a patient taking a dietary supplement not normally considered to contain digoxin. In addition to highlighting the risks of herbal supplements, this case also demonstrates the concept that digoxin equivalents are not picked up by the standard digoxin assay.

Topics: Adult; Bradycardia; Digoxin; Female; Humans; Hypotension; Immunoassay; Plants, Medicinal; Stress, Psychological

Topics: Aged; Aged, 80 and over; Atrial Flutter; Bradycardia; Cardiotonic Agents; Diagnosis, Differential; Digoxin; Electrocardiography; Female; Humans

Nine cases of symptomatic bradycardia are presented in which treatment with intravenous glucagon was administered when atropine failed to improve the patient's condition significantly. Although the cause often was not obvious at presentation, all nine subjects took oral medications that could have contributed to the development of symptomatic bradycardia. Eight of nine patients demonstrated clinical improvement 5 to 10 min after glucagon administration, which was consistent with its peak clinical action. Beta-blockers, calcium channel blockers, and digoxin were ultimately thought to have contributed to the majority of these presentations. This report suggests that glucagon may have a role in the treatment of symptomatic bradycardia, particularly in the presence of beta-adrenergic blockade and perhaps calcium channel blockade. Furthermore, the results in these cases suggest that future clinical trials should not be limited to drug-induced symptomatic bradycardia.

Topics: Adrenergic beta-Antagonists; Aged; Aged, 80 and over; Anti-Arrhythmia Agents; Atropine; Blood Pressure; Bradycardia; Calcium Channel Blockers; Clinical Trials as Topic; Digoxin; Female; Glucagon; Heart Rate; Humans; Infusions, Intravenous; Male; Middle Aged; Time Factors; Treatment Outcome

Topics: Animals; Antibodies, Monoclonal; Bradycardia; Cardiac Complexes, Premature; Cardiotonic Agents; Digoxin; Electrocardiography; Guinea Pigs; Heart; Heart Conduction System; Male

There are a lot of publications about fetal arrhythmia in singletons, but up to now there are no published data about fetal arrhythmia in multiple pregnancies. In the present study a case history of fetal and neonatal arrhythmia in one of twins from two mothers treated with betamimetic agents due to imminent preterm labor is reported and discussed. A first case with fetal bradycardia due to complete A-V block had congenital cordis abnormalities (VSD and PFO). The second case with prenatal detected extrasystoles had normal heart anatomy. Digoxin was administered to the mother, in the aim to treat fetal arrhythmia without success, because the baby had postnatal bradycardia. After hospitalisation in Cardiology Department the described cases were successfully treated. In both cases the second twins were without neonatal arrhythmia and with no structural heart abnormalities. We summarise that in situation of detection fetal arrhythmia the complexity of the problems experienced may warrant early referral to a tertiary centre where the overall management of the mother, fetus and neonate, may be undertaken.

Topics: Arrhythmias, Cardiac; Bradycardia; Cardiac Complexes, Premature; Digoxin; Diseases in Twins; Female; Fetal Diseases; Fetal Heart; Gestational Age; Heart Block; Humans; Infant, Newborn; Infant, Newborn, Diseases; Male; Obstetric Labor, Premature; Pregnancy; Twins; Ultrasonography, Prenatal

Digoxin intoxication is a serious medical problem, and impairment of renal function is a common risk factor for toxicity. Digoxin specific antibody fragments (Fab) is the most effective treatment available for severe digitalis intoxication. The use of Fab therapy in a patient with renal disease is considered as effective as in patients with normal renal function, although the increased risk of rebound digoxin toxicity mandates a longer period of observation. In patients with kidney failure, neither digoxin nor Fab can be removed efficiently from the systemic circulation by hemodialysis or continuous arteriovenous hemofiltration. Knowledge about the clearance of both compounds by peritoneal dialysis is limited. The authors describe a patient with end stage renal disease who was treated with Fab and peritoneal dialysis for life threatening digoxin intoxication. Like other forms of dialysis, peritoneal dialysis, even when performed in an intensive schedule, is not associated with an enhanced clearance of digoxin.

Topics: Biological Availability; Bradycardia; Cardiotonic Agents; Digoxin; Drug Monitoring; Electrocardiography; Half-Life; Humans; Immunoglobulin Fab Fragments; Kidney Failure, Chronic; Male; Middle Aged; Peritoneal Dialysis; Tachycardia

A case is presented of cardiac glycoside poisoning in a 1-year-old patient from the plant Nerium oleander (common oleander). The patient had bradycardia, vomiting, altered level of consciousness, and no history of ingestion. Antibody-based digoxin assays may cross-react with other cardiac glycosides nonquantitatively. Chromatographic techniques can be used in the specific diagnosis.

Topics: Animals; Anti-Arrhythmia Agents; Bradycardia; Cardenolides; Chromatography, High Pressure Liquid; Cross Reactions; Digoxin; False Positive Reactions; Glycosides; Humans; Immunoassay; Infant; Male; Plant Poisoning; Vomiting

Toxicity from toad venom poisoning is similar to digoxin toxicity and carries a high mortality rate. We report on six previously healthy men who developed vomiting and bradycardia after ingesting a purported topical aphrodisiac. Each patient had positive apparent digoxin levels and the first four patients died of cardiac dysrhythmias. The last two patients recovered following treatment with digoxin Fab fragments. We analyzed samples of the purported aphrodisiac and found that it was identical to Chan Su, a Chinese medication made from toad venom. To our knowledge, this is the first reported use of digoxin Fab fragments to treat toad venom poisoning.

Topics: Adolescent; Adult; Amphibian Venoms; Animals; Aphrodisiacs; Bradycardia; Bufanolides; Bufonidae; Bufotenin; Digoxin; Fatal Outcome; Humans; Immunoglobulin Fab Fragments; Male; Materia Medica; Ventricular Fibrillation; Vomiting

Gitaloxin is a digitalis glycoside used for the same indications as digoxin and digitoxin. The successful outcome for a 2 1/2-year-old boy who accidentally ingested 3 mg of gitaloxin (100 times the normal therapeutic dose) is reported. At admission the child presented with irregular heart rhythm. He subsequently started vomiting, even after continuous gastric feeding. Only 48 h after ingestion of gitaloxin he became somnolent and developed bradyarrhythmia. The symptoms disappeared 96 h later; the bradyarrhythmia, however, (second-degree atrioventricular block) decreased progressively only after 120 h. The initial clinical presentation of gitaloxin poisoning may be misleading and careful observation in a pediatric intensive care unit is mandatory. A cross-reaction between the fluorescence polarization immunoassay for digitoxin and the radioimmunoassay for gitaloxin was found and was used as a helpful, but rough, estimate of the severity of gitaloxin poisoning, in the absence of a specific measurement of gitaloxin.

Topics: Bradycardia; Child, Preschool; Critical Care; Digoxin; Electrocardiography; Fluorescence Polarization Immunoassay; Humans; Male; Poisoning; Vomiting

Topics: Aged; Bradycardia; Digoxin; Drug Interactions; Humans; Itraconazole; Male

Orthotopic cardiac transplantation is occasionally complicated by unexplained bradyarrhythmias. Sinus node injury as a consequence of operation or acute rejection has anecdotally been linked to the development of bradycardia early after transplantation. These arrhythmias are empirically managed by pacemaker implantation, the indications for which remain poorly defined. This retrospective study examined the 20-year experience of our institution with bradyarrhythmias after transplantation to determine the predisposing factors and indications for pacemaker implantation. Forty-one of 556 patients in our cardiac transplant program (7.4%) received permanent pacemakers between 1969 and 1989. The predominant rhythm disturbances were junctional rhythm (46%), sinus arrest (27%) and sinus bradycardia (17%). Most patients were asymptomatic (61%), and presented in the early post-transplant period (73%). Four possible predisposing factors were evaluated: (1) graft ischemic time, (2) rejection history, (3) use of bradycardia-inducing drugs, and (4) anatomy of blood supply to the sinoatrial (SA) node. No significant differences existed between patients with and without pacemakers with regard to the first 3 variables. However, after transplantation angiograms showed that prevalence of abnormal SA nodal arteries was greater in patients with than without pacemakers (p less than 0.02). Pacemaker follow-up at 3, 6 and 12 months showed persistent bradycardia (60 to 90 beats/min) in 88, 75 and 50% of patients, respectively. The most common pacemaker complication (15%) was lead displacement at time of biopsy. These results suggest that disruption of the SA nodal blood supply may be an important predisposing factor in the development of bradycardias.

Topics: Adolescent; Adult; Angiography; Bradycardia; Child; Child, Preschool; Digoxin; Follow-Up Studies; Graft Rejection; Heart Transplantation; Humans; Middle Aged; Pacemaker, Artificial; Retrospective Studies; Sinoatrial Node

The case of a 5-year-old girl who survived a near-fatal ingestion of yew plant leaves after treatment with CPR, transcutaneous pacing, and digoxin-specific FAB antibody fragments is presented. Multiple rhythm disturbances, including profound bradycardia, occurred. She required endotracheal intubation, external chest compressions, and application of a transcutaneous pacemaker. Paced cardiac contractions produced a dramatic improvement in her blood pressure and clinical condition. Two empiric injections of digoxin-specific FAB antibody fragments were administered, after which cardiac function and rhythm gradually improved. She was discharged in her normal state of health three days later. Yew leaves and berries contain several alkaloids that can produce fatal conduction disturbances. Transcutaneous cardiac pacemakers may be lifesaving for patients with transient cardiac toxicity from drug or toxin ingestions. In addition, cross-reactivity between digoxin-specific FAB antibodies and the alkaloids in the yew plant may exist and may have therapeutic importance, although this mechanism was unlikely to have helped our patient.

Topics: Bradycardia; Cardiac Pacing, Artificial; Child, Preschool; Combined Modality Therapy; Digoxin; Electrocardiography; Female; Heart Block; Humans; Immunoglobulin Fab Fragments; Plant Poisoning

Topics: Bradycardia; Digoxin; Drug Interactions; Erythromycin; Female; Humans; Middle Aged; Nausea; Risk Factors; Vomiting

A 37-year-old man presented two hours after the ingestion of "a handful" of oleander leaves (probably Nerium oleander) in a suicide attempt. Cardiotoxicity was evidenced by the presence of bradycardia (rate, 30 to 45) with sinoatrial nodal arrest and junctional escape consistent with a cardiac glycoside effect. The patient was treated empirically with a single dose of five vials (200 mg) of digoxin-specific Fab antibody fragments (Digibind). The pretreatment digoxin level was 1.5 ng/mL. After treatment, the patient's rhythm stabilized with residual sinus bradycardia (rate, 56). The patient recovered uneventfully and was discharged on the fifth hospital day to inpatient psychiatric care.

Topics: Adult; Bradycardia; Cardiac Glycosides; Digoxin; Electrocardiography; Humans; Immunoglobulin Fab Fragments; Male; Plant Poisoning; Suicide, Attempted

The problem of a possible interaction between amiodarone and digoxin is still unsettled. We have recently treated two patients with digoxin intoxication who had received amiodarone for eight and 36 months respectively. Both developed extreme bradycardia requiring temporary pacemakers. The presence of hypothyroidism was confirmed in both cases by laboratory data. Judging by present knowledge concerning the interaction between amiodarone, thyroid function, and digoxin, it is suggested that digoxin intoxication was not the result of its direct interaction with amiodarone. The possibility that amiodarone-induced hypothyroidism precipitated digoxin intoxication seems to be more plausible. Prevention of digitalis toxicity in amiodarone-treated patients would therefore require monitoring of thyroid function every three to six months. Frequent monitoring of digitalis blood levels is also indicated in patients with amiodarone associated hypothyroidism. Early detection of hypothyroidism and digitalis intoxication is necessary in view of the severity of the course of the disease.

Topics: Aged; Amiodarone; Benzofurans; Bradycardia; Digoxin; Drug Interactions; Electrocardiography; Female; Heart Block; Humans; Hypothyroidism; Male

Topics: Adult; Antibody Specificity; Bradycardia; Digoxin; Humans; Immunoglobulin Fab Fragments; Male; Middle Aged; Time Factors

Topics: Antibodies; Antibody Specificity; Antidotes; Bradycardia; Child, Preschool; Digoxin; Female; Humans; Immunoglobulin Fab Fragments; Infusions, Parenteral; Medigoxin

Topics: Bradycardia; Bundle-Branch Block; Digoxin; Humans; Male; Middle Aged

Preexisting anomalies of impulse formation and conduction, cardiac failure, myocardial ischemia and abnormal peripheral vasoregulation predispose the elderly patient to frequent and often severe side-effects of antiarrhythmic drugs. Paroxysmal supraventricular tachycardia in patients with sick sinus syndrome can be especially difficult to treat, as most antiarrhythmics further prolong the sinus node recovery time. Thus, implantation of a pacemaker is often necessary to prevent symptomatic bradycardia. Concomitant treatment with diuretics or digitalis also increases the risk of drug induced ventricular dysrhythmias. Interaction between quinidine, verapamil, amiodarone and digoxin may be the reason for drug toxicity. To compensate for decreased renal or metabolic drug clearances antiarrhythmic treatment in elderly patients should be initiated with lower doses than usual.

Topics: Aged; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Bradycardia; Digoxin; Heart Ventricles; Hemodynamics; Humans; Kidney Function Tests; Liver Function Tests; Metabolic Clearance Rate; Risk; Tachycardia

We studied the direct effects of digitalis on sinoatrial conduction time (SACT), atrial rate (AR) and developed tension (DT) in isolated atrial muscle, using an isolated dog atrial preparation perfused with heparinized blood from the carotid artery of an anesthetized donor dog. After digoxin or deslanoside (100 micrograms or 200 micrograms/Kg) was given intravenously to the donor dog, SACT, AR and DT of the isolated atrium were continuously measured. Following administration of 100 micrograms/Kg of digoxin, an immediate sinus bradycardia followed by various kinds of ventricular arrhythmias was observed in the donor dog, and the DT of the isolated atrium was augmented without any effects on the SACT and AR in all 3 experiments. With 200 micrograms/Kg of digoxin or deslanoside, ventricular fibrillation was induced in all 5 donor dogs within 75 min after digitalis administration. In these cases, the DT of the isolated atrium was immediately increased to over 200% of control DT, but SACT and AR were not affected until 20 min later, at which time increases in SACT and AR were finally induced. From these results, it is concluded that a large amount of digitalis has no distinct direct effect on SA nodal pacemaker activity and SA conductivity. Moreover, extremely large doses of digitalis which cause ventricular fibrillation might also induce a prolongation of SACT in addition to sinus tachycardia.

Topics: Animals; Bradycardia; Deslanoside; Digoxin; Dogs; Dose-Response Relationship, Drug; Heart Atria; Heart Rate; Lanatosides; Myocardial Contraction; Perfusion; Sinoatrial Node; Tachycardia

After noting bradycardia-induced supraventricular tachycardia (SVT) in two successive children with SVT, we analyzed Holter monitor recordings done on 66 children with suspected or proved SVT. Ten children had apparent reentry SVT. The most common mode of initiation (eight of 10 patients) was not premature atrial beats, but sudden sinus pause with a junctional escape beat (JEB), usually fused with the delayed sinus P wave, initiating the tachycardia. Electrophysiologic studies in five children who had this mode of initiation showed evidence of reentry in four, possibly by dual atrioventricular nodal (AVN) pathways. Since sudden sinus pause and JEB are relatively uncommon in adults, the disappearance of this phenomenon with age may be the most significant reason why children often have less tachyarrhythmia as they get older. Both propranolol and digoxin significantly increased the numbers of episodes of SVT in the three patients tested with serial Holter monitoring.

Topics: Adolescent; Atrioventricular Node; Bradycardia; Cardiac Pacing, Artificial; Child; Child, Preschool; Digoxin; Electrocardiography; Humans; Propranolol; Tachycardia

Eighteen infants, each weighing less than 1,500 gm, were treated with low dose digoxin therapy for patent ductus arteriosus and signs of circulatory congestion. Nine of the 18 developed one or more signs of clinical deterioration felt to be related to digoxin therapy: eight infants experienced frequent episodes of bradycardia, six had cardiac arrhythmias, and six experienced feeding difficulties. All signs disappeared when digoxin therapy was discontinued. Digoxin, even in relatively low dosages, can have deleterious complications in seriously ill low-birth-weight infants. Alternatives to digoxin in this patient population should be considered before institution of digoxin therapy.

Topics: Arrhythmias, Cardiac; Bradycardia; Digoxin; Ductus Arteriosus, Patent; Feeding Behavior; Humans; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature, Diseases

Topics: Animals; Bradycardia; Brain; Digoxin; Dogs; Female; Heart Rate; Male; Receptors, Cholinergic; Receptors, Histamine; Tachycardia

1 A thyrotoxic patient receiving a constant dose of propranolol and digoxin developed marked bradycardia postoperatively. 2 Compared to preoperative levels there was a considerable rise post-operatively in both plasma propranolol and serum digoxin steady-state concentrations. 3 Surgery by effecting drug disposition and disease processes may significantly alter drug handling in the perioperative period.

Topics: Bradycardia; Digoxin; Female; Humans; Metabolic Clearance Rate; Middle Aged; Pharmaceutical Preparations; Postoperative Complications; Propranolol; Surgical Procedures, Operative; Thyroidectomy

Topics: Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Atropine; Bradycardia; Cardiac Complexes, Premature; Digoxin; Heart Block; Heart Failure; Humans; Lidocaine; Myocardial Infarction; Propranolol; Tachycardia

Certain arrhythmias detected on the electrocardiogram are considered to be reliable indicators of digitalis intoxication. We have evaluated the incidence of these arrhythmias on 24-hour electrocardiographic monitoring (Holter monitoring) in 69 consecutive patients who had serum levels of digoxin determined within 24 hours of the onset of continuous electrocardiographic monitoring. According to teh serum level of digoxin, the patients were divided into the following three groups: (1) group 1 had 0 to 1.0 ng/ml (31 patients); (2) group 2 had 1.1 to 2.0 ng/ml (27 patients); and group 3 had greater than or equal to 2.1 ng/ml (11 patients). The following arrhythmias were considered to reflect digitalis-provoked arrhythmias: (1) persistent sinus bradycardia or sinus pauses (or both); (2) atrioventricular block; (3) paroxysmal atrial tachycardia with block; (4) accelerated junction rhythm; (5) complex ventricular arrhythmias (multifocal ventricular premature beats, bigeminy and trigeminy, and pairs); and (6) ventricular tachycardia. There was no significant difference in the incidence of these six categories of arrhythmias among the three groups. In addition, there was no significant difference in the mean serum level of digoxin for patients with and without the arrhythmias within each category. Ten of the 69 patients had combinations of three of the so-called digitalis-provoked arrhythmias, with incidences among the three groups showing no significant differences. In conclusion, rhythms considered to be potentially due to digitalis intoxication are frequently observed in hospitalized patients undergoing 24-hour electrocardiographic monitoring, are frequently unrelated to the serum level of digoxin, and appear unlikely to reflect true digitalis intoxication in many of these patients.

Topics: Aged; Arrhythmias, Cardiac; Bradycardia; Digoxin; Electrocardiography; Heart Block; Humans; Monitoring, Physiologic; Retrospective Studies; Tachycardia

In 12 normal subjects (group I), in 12 subjects with asymptomatic sinus bradycardia (group II) and in 18 patients with symptomatic sick sinus syndrome (group III), sinus node cycle length (SNCL), sinus node recovery time (SNRT), corrected sinus node recovery time (CSNRT), sino-atrial conduction time (SACT), have been evaluated before and after an acute digoxin administration. Mean value of SNCL lengthened significantly in all groups. Mean value of SNRT increased moderately in the first group, remarkably in the third group, whereas it showed a mild but statistically insignificant increase in the second group. Mean value of CSNRT was significantly lengthened only in the third group. Mean value of SACT showed a mild but statistically insignificant lengthening in all groups. In order to investigate the importance of the parasympathetic action induced by digitalis, in 4 normal subjects, in 4 patients with asymptomatic sinus bradycardia, and in 10 patients with symptomatic sick sinus syndrome, SNCL, CSNRT and SACT has been evaluated after an intravenously, administration of atropine, following digoxin. In the paper the intricate mechanisms by which digitalis affects the parameters of sinus nodal function especially in patients with symptomatic sick sinus syndrome, are discussed. In disagreement with the mot papers reported in the literature we think that an acute digoxin administration is able to worsen the electrophysiological parameters of sinus nodal function especially in patients with symptomatic sick sinus syndrome.

Topics: Adult; Aged; Bradycardia; Digoxin; Electrophysiology; Humans; Middle Aged; Sick Sinus Syndrome; Sinoatrial Node

Topics: Bradycardia; Digoxin; Humans

Topics: Age Factors; Bradycardia; Digoxin; Heart Rate; Humans; Male; Middle Aged

To increase the limited knowledge of the effects of digitalis on sinus nodal function in patients with sinus nodal dysfunction and to initiate an investigation into the mechanisms underlying its effects, 34 patients with sinus nodal dysfunction were studied. Twenty patients underwent determination of sinus cycle length, estimated sinoatrial conduction time and maximal corrected sinus recovery time before and after the administration of 0.75 mg of intravenous digoxin. For the group, sinus cycle length did not change, sinoatrial conduction time increased insignificantly and maximal corrected sinus recovery time shortened; however, individual variation occurred. The effects of acute digitalization appeared to predict the effects of chronic digitalis administration on sinus nodal function in the eight patients who subsequently continued to take digoxin. Fourteen patients received digoxin after vagal blockade with atropine. After vagal blockade, digoxin lengthened sinus cycle length, sinoatrial conduction time and maximal corrected sinus recovery time. The effects of digoxin administered after atropine could be antiadrenergic, direct, or both, and are opposite to those induced by atropine alone. Because these effects are similar to those of vagotonia yet are not apparent when the vagi are unblocked, digoxin may have direct excitatory, adrenergic or previously unrecognized vagolytic effects on sinus nodal function in man and their manifestation may be dependent on heart rate or autonomic tone.

Topics: Adult; Aged; Arrhythmias, Cardiac; Atropine; Bradycardia; Cardiac Pacing, Artificial; Digoxin; Electrocardiography; Female; Humans; Injections, Intravenous; Male; Middle Aged; Sinoatrial Block; Sinoatrial Node; Tachycardia; Vagus Nerve

Serum digoxin levels, estimated by radioimmuno assay, technique, and the pattern of cardiac arrhythmias due to digoxin intoxication seem to be correlated in cases with high serum digoxin levels. The prognostic value of those correlations is demonstrated and discussed. Serial observations of the course of cardiac arrhythmias under the suspicion of digoxin intoxication together with blood level measurements allow to introduce more objective criteria in clinical management of poor risk patients receiving digoxin.

Topics: Arrhythmias, Cardiac; Bradycardia; Cardiac Complexes, Premature; Cardiac Glycosides; Digoxin; Heart Block; Humans; Tachycardia

Arrhythmias were analyzed in 50 patients undergoing cardiac surgery: 27 with valve surgery, 15 with coronary artery bypass (CAB), 5 with CAB and valve surgery, and 3 with miscellaneous procedures. The role of electrolyte abnormalities, pericarditis, serum osmolarity, digoxin level, and the type of surgery performed was evaluated. Thirty-seven out of 50 patients (74 per cent) had a postoperative arrhythmia, and a total of 78 different arrhythmias were noted. Twenty-six out of 27 patients with valve surgery had an arrhythmia vs. six out of 15 patients with CAB (p less than 0.001). Atrial fibrillation was the most common arrhythmia in all groups. Although postoperative hypocalcemia, hypomagnesemia, pericarditis, and wide shifts in osmolarity were common, they did not correlate with arrhythmias. Seventeen patients developed postoperative arrhythmias compatible with digitalis toxicity, including junctional rhythm, atrioventricular dissociation, or atrial tachycardia with block. However, the range of serum digoxin levels in these patients was zero to 2.80 ng. per milliliter. This suggests increased sensitivity to digitalis glycosides or the effects of surgical trauma as the etiology of arrhythmia in many patients. The distinction between digitalis-induced arrhythmia and spontaneously occurring arrhythmia cannot be made with certainty in most postoperative patients. Therapy should reflect an awareness of the potential for postoperative digitoxicity.

Topics: Aortic Valve; Arrhythmias, Cardiac; Blood; Bradycardia; Bundle-Branch Block; Calcium; Carbon Dioxide; Cardiac Surgical Procedures; Coronary Artery Bypass; Creatinine; Digoxin; Heart Auscultation; Heart Block; Heart Valve Prosthesis; Humans; Hydrogen-Ion Concentration; Magnesium; Mitral Valve; Osmolar Concentration; Postoperative Complications; Potassium; Serum Albumin; Sodium; Tachycardia, Paroxysmal; Time Factors

Topics: Animals; Arrhythmias, Cardiac; Blood Pressure; Bradycardia; Cardiovascular Diseases; Digoxin; Emergencies; Epinephrine; Female; Fetal Diseases; Fetal Heart; Haplorhini; Heart Failure; Heart Rate; Humans; Hypoxia; Infant; Infant, Newborn; Infant, Newborn, Diseases; Isoproterenol; Lidocaine; Pregnancy; Radiography; Resuscitation; Transposition of Great Vessels

The effects of potassium canrenoate on arrhythmias induced by long-term progressive digoxin toxicity were studied in eight conscious beagle dogs. Sinus bradycardia and sinoatrial block, as well as atrioventricular (A-V) conduction disturbances, were consistently alleviated by administration of potassium canrenoate. Premature supraventricular (including junctional) and ventricular depolarizations as well as ventricular tachycardias were also suppressed. Although potassium canrenoate always terminated the digitalis-induced arrhythmias, it usually converted the rhythm to sinus arrhythmia rather than to normal sinus rhythm. Equimolar sodium canrenoate, but not potassium chloride, had similar reversal effects on arrhythmias induced by long-term digoxin intoxication. These data indicate that canrenoate, a diuretic agent with reported positive inotropic effects, may be useful in the treatment of digitalis-induced arrhythmias in man.

Topics: Animals; Arrhythmia, Sinus; Arrhythmias, Cardiac; Atrioventricular Node; Bradycardia; Bundle of His; Digoxin; Diuretics; Dogs; Electrocardiography; Female; Heart Block; Heart Ventricles; Ketosteroids; Male; Mineralocorticoid Receptor Antagonists; Potassium; Potassium Chloride; Pregnadienes; Sodium; Tachycardia

Topics: Aged; Bradycardia; Digoxin; Electrocardiography; Female; Heart Conduction System; Humans; Propranolol; Tachycardia

Digoxin, in a common clinical dose and at a low serum level, brought out severe manifestations of sinus node dysfunction in a patient who had previously undergone successful mitral valve replacement. This report presents the results of extensive clinical and electrophysiologic studies of this patient before and after a digoxin challenge. In the absence of cardiac glycoside, the only demonstrable abnormalities of sinus node function were mild resting sinus bradycardia and failure to respond to atropine administration. Responses to isoproterenol administration, programmed premature atrial stimulation, and overdrive pacing at several cycle lengths were normal. Following the administration of intravenous digoxin, 1.025 mg/24 hrs, the resting sinus cycle length increased and the response to overdrive pacing became markedly abnormal. The latter was followed by sinus pauses in excess of six seconds, even at relatively slow overdrive pacing rates. The electrophysiologic and clinical implications of these data are discussed. It is suggested that despite previous reports that digitalis preparations are relatively well tolerated by patients with sick sinus syndrome, caution should be used when administering these drugs to this group of patients.

Topics: Arrhythmia, Sinus; Atrioventricular Node; Atropine; Bradycardia; Digoxin; Electrocardiography; Heart Conduction System; Heart Failure; Heart Rate; Humans; Isoproterenol; Male; Middle Aged; Sinoatrial Node; Syndrome; Tachycardia

In 20 children needing treatment for symptomatic sick sinus syndrome, the average age at presentation was 7.1 years and ranged from 9 months to 18 years. Symptoms were never precise but, in retrospect, 5 children had syncope, 7 had a rapid heart action, 6 had dyspnoea or tachypnoea, 2 had nonspecific chest pains, 2 had pale spells, and 1 had a sudden hemiplegia. Symptoms followed cardiac surgery in 15 cases and were related to unoperated congenital heart disease in 2 and to myocarditis in 2. The aetiology was unknown in 1 case. The type of cardiac surgery resulting in the development of the sick sinus syndrome was predominantly related to atrial suturing. Both tachy- and bradydysrhythmias were found, including wandering atrial pacemaker (9 cases), junctional rhythm (19 cases), supraventricular tachycardia (9 cases), atrial flutter (11 cases), and atrial fibrillation (2 cases). Both atrial (8 cases) and ventricular (7 cases) premature beats were seen. All patients were given trials of drug therapy but difficulties were encountered. Cardioversion was used for tachyarrhythmias in 11 cases without serious problems. Six children had permanent cardiac pacemakers inserted with good results. Recognition of the sick sinus syndrome in childhood is important and treatment must be regulated by the severity of symptoms.

Topics: Adolescent; Arrhythmia, Sinus; Arrhythmias, Cardiac; Bradycardia; Cardiac Catheterization; Child; Child, Preschool; Digoxin; Dyspnea; Female; Heart Block; Heart Defects, Congenital; Heart Rate; Hemiplegia; Humans; Infant; Male; Myocarditis; Pacemaker, Artificial; Pallor; Syncope

Plasma digoxin and digitoxin determination has proven to have an important bearing, particularly in patients with renal failure. It permits early detection of digitalis intoxication in the absence of marked clinical and ECG evidence, and adjustment of dosage accordingly. Also, in patent intoxication it makes it possible to select the right moment for resumption of therapy. To illustrate the importance of the method some cases are cited involving plasma digoxin and digitoxin determination.

Topics: Acute Kidney Injury; Bradycardia; Creatinine; Digitalis Glycosides; Digitoxin; Digoxin; Heart Failure; Humans; Kidney Failure, Chronic

Topics: Adolescent; Adult; Aged; Arrhythmias, Cardiac; Blood Pressure; Bradycardia; Digoxin; Electrocardiography; Female; Heart Ventricles; Humans; Injections, Intravenous; Male; Methyldopa; Middle Aged; Syndrome; Tachycardia; Tachycardia, Paroxysmal; Verapamil; Wolff-Parkinson-White Syndrome

Topics: Aged; Animals; Atropine; Bradycardia; Coronary Disease; Digoxin; Female; Heart Block; Heart Failure; Humans; Injections, Intravenous; Lidocaine; Male; Myocardial Infarction; Rabbits

Topics: Adult; Arrhythmia, Sinus; Bradycardia; Digoxin; Electrocardiography; Female; Fetus; Humans; Pacemaker, Artificial; Pregnancy; Pregnancy Complications, Cardiovascular; Tachycardia

Topics: Aged; Arrhythmias, Cardiac; Bradycardia; Digoxin; Female; Heart Block; Heart Diseases; Humans; Hypertension; Middle Aged; Pacemaker, Artificial; Sinoatrial Node; Syncope

Topics: Acute Disease; Adult; Atropine; Bradycardia; Digoxin; Electrocardiography; Female; Furosemide; Humans; Hyperkalemia; Intensive Care Units; Pacemaker, Artificial; Poisoning; Radioimmunoassay; Suicide

Topics: Adenosine; Animals; Bradycardia; Bufanolides; Cardiac Glycosides; Cardiac Output; Digitalis Glycosides; Digitoxin; Digoxin; Guinea Pigs; Heart Arrest; Heart Block; Infusions, Parenteral; Lethal Dose 50; Mathematics; Ouabain; Plants, Medicinal; Time Factors

Topics: Bradycardia; Bundle-Branch Block; Digitalis Glycosides; Digoxin; Electrocardiography; Female; Humans; Middle Aged

Topics: Arrhythmias, Cardiac; Atropine; Bradycardia; Digoxin; Electrocardiography; Heart Arrest; Heart Atria; Heart Block; Heart Conduction System; Humans; Hyperkalemia; Male; Middle Aged; Pacemaker, Artificial; Time Factors

Topics: Adolescent; Adult; Aged; Animals; Arrhythmias, Cardiac; Atrial Fibrillation; Atrial Flutter; Bradycardia; Cardiac Catheterization; Digoxin; Dogs; Electrocardiography; Electrodes, Implanted; Female; Functional Laterality; Heart Atria; Heart Conduction System; Humans; Male; Middle Aged; Ouabain; Pacemaker, Artificial; Tachycardia; Vagotomy

Topics: Anesthesia, Intravenous; Animals; Atropine; Blood Pressure; Bradycardia; Chloralose; Digoxin; Dogs; Drug Interactions; Electrocardiography; Heart Rate; Pentobarbital; Time Factors; Urethane; Vagotomy; Vagus Nerve

Topics: Acute Disease; Arrhythmias, Cardiac; Bradycardia; Digoxin; Electrocardiography; Humans; Hypercalcemia; Male; Middle Aged; Nausea; Suicide; Vomiting

Topics: Adrenergic beta-Agonists; Aged; Atrial Fibrillation; Bradycardia; Cerebrovascular Disorders; Digitalis Glycosides; Digoxin; Heart Block; Heart Failure; Humans

Topics: Aged; Analgesia; Anti-Arrhythmia Agents; Blood Volume; Bradycardia; Cardiovascular Diseases; Diazepam; Digoxin; Diuretics; Dopamine; Glucagon; Heart Failure; Humans; Hypertension; Hypotension; Male; Myocardial Infarction; Norepinephrine; Phentolamine; Plasma Substitutes; Potassium; Tachycardia

Topics: Adult; Aged; Bradycardia; Digoxin; Female; Humans; Hyperkalemia; Male

Topics: Adult; Aged; Arrhythmias, Cardiac; Bradycardia; Coronary Care Units; Digoxin; Diuretics; Electrocardiography; Female; Heart Atria; Heart Block; Heart Failure; Heart Ventricles; Hospitals, Teaching; Humans; Male; Middle Aged; Myocardial Infarction; Prognosis; Shock, Cardiogenic; Tachycardia; Ventricular Fibrillation

Topics: Angina Pectoris; Atrial Fibrillation; Bradycardia; Cardiac Catheterization; Diagnosis, Differential; Diagnostic Errors; Digoxin; Electrocardiography; Humans; Hyperthyroidism; Lidocaine; Male; Middle Aged; Myocardial Infarction; Procainamide; Tachycardia; Tachycardia, Paroxysmal; Thyroxine

Topics: Arrhythmias, Cardiac; Bradycardia; Digoxin; Electric Countershock; Electrocardiography; Humans; Isoproterenol; Lidocaine; Pacemaker, Artificial; Tachycardia

Topics: Aging; Animals; Aorta; Body Weight; Bone and Bones; Bradycardia; Calcium; Digoxin; Feeding Behavior; Female; Heart Rate; Hypothalamus; Longevity; Male; Mass Spectrometry; Mice; Microscopy, Electron; Minerals

Topics: Acute Disease; Bradycardia; Digoxin; Female; Hearing Disorders; Heart Diseases; Heart Failure; Humans; Myocardial Infarction; Nitroglycerin; Vestibular Function Tests

Topics: Aged; Arrhythmias, Cardiac; Bradycardia; Coronary Disease; Digoxin; Electrocardiography; Heart Block; Humans; Hypertension; Ischemic Attack, Transient; Middle Aged; Rheumatic Heart Disease; Syncope; Tachycardia

Topics: Aged; Bradycardia; Digitalis Glycosides; Digitoxin; Digoxin; Electrocardiography; Female; Heart Auscultation; Heart Diseases; Hemodynamics; Humans; Male; Middle Aged; Muscle Contraction; Plants, Medicinal

Topics: Anti-Bacterial Agents; Anticoagulants; Aortic Coarctation; Bradycardia; Chlorothiazide; Diet, Sodium-Restricted; Digitalis Glycosides; Digitoxin; Digoxin; Drug Tolerance; Electrocardiography; Endocardial Fibroelastosis; Furosemide; Heart Block; Heart Defects, Congenital; Heart Failure; Humans; Infant; Infant, Newborn; Infant, Newborn, Diseases; Lanatosides; Myocarditis; Organomercury Compounds; Oxygen Inhalation Therapy; Potassium Chloride; Pulmonary Edema; Tachycardia; Tachycardia, Paroxysmal; Transposition of Great Vessels

Topics: Aged; Bradycardia; Digitalis Glycosides; Digoxin; Humans; Pulse

Topics: Aged; Arrhythmias, Cardiac; Atrial Fibrillation; Atropine; Bradycardia; Cardiac Complexes, Premature; Digoxin; Drug Hypersensitivity; Dyspnea; Heart Rate; Humans; Male; Middle Aged; Propranolol; Tachycardia; Uremia

Topics: Aged; Bradycardia; Digoxin; Humans; Male; Pacemaker, Artificial; Propranolol; Tachycardia

Topics: Adams-Stokes Syndrome; Bradycardia; Digitalis; Digoxin; Electrocardiography; Heart Arrest; Heart Rate; Humans; Myocardial Infarction; Plants, Medicinal; Plants, Toxic; Procainamide; Propranolol; Quinidine; Sympathomimetics

Topics: Angiocardiography; Bradycardia; Cardiomegaly; Digoxin; Electrocardiography; Female; Heart Block; Heart Septal Defects, Ventricular; Hepatomegaly; Humans; Hypertension, Pulmonary; Infant; Pacemaker, Artificial

Topics: Arrhythmia, Sinus; Arrhythmias, Cardiac; Blood Chemical Analysis; Blood Pressure; Blood Pressure Determination; Bradycardia; Calcium; Calcium, Dietary; Child; Digitalis; Digitalis Glycosides; Digoxin; Electrocardiography; Electroencephalography; Humans; Hydrogen-Ion Concentration; Infant; Potassium; Sodium; Toxicology; Urea; Water-Electrolyte Balance

Topics: Bradycardia; Delirium; Digitalis; Digitalis Glycosides; Digitoxin; Digoxin; Gynecomastia; Humans; Lanatosides; Male; Neuritis; Paresthesia; Tachycardia; Thrombocytopenia; Toxicology; Trigeminal Neuralgia; Urticaria