digoxin and Cardiac-Output--Low

Based on multiple randomized controlled trials performed in the last 20 years, drugs form the basis of treatment for heart failure with reduced ejection fraction (HFREF). Despite solid evidence for their efficacy and safety and publication of detailed national and international guidelines many patients with HFREF remain, who are not at all or only insufficiently treated. Treatment goals include reduction of mortality and hospitalizations, improvement of symptoms and exercise tolerance as well as prevention of disease progression. ACE-inhibitors and beta-adrenergic receptor blockers exert beneficial effects on all treatment goals and are therefore indicated in all patients with HFREF if tolerated. Diuretics allow control of fluid retention and maintenance of "euvolemia". Low-dose spironolactone can be considered in persistent moderate to severe (NYHA 3 - 4) HFREF despite treatment. Angiotensin receptor blockers are indicated for ACE-inhibitor intolerance or in addition to ACE-inhibitors and beta-adrenergic receptor blockers in case of persistent symptoms. Triple combination of ACE-inhibitors, angiotensin receptor blockers and aldosterone antagonists should be avoided in view of the substantial risk of hyperkalemia. In current praxis digoxin is mainly used as an adjunctive agent for rate control of atrial fibrillation in combination with beta-adrenergic receptor blockers. Titration and maintenance of heart failure treatment requires continuous control of clinical parameters, renal function and electrolytes. It is recommended to use drugs and dosest hat have been shown to be effective in clinial trials. Despite the fact that heart failure is mainly a disease of the elderly, this population is underrepresented in clinical trials. The risk of side effects and drug-drug interactions is increased in elderly patients because of physiologic changes with age and frequent comorbidities with resultant polypharmacy.

Topics: Adrenergic beta-Antagonists; Aged; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Atrial Fibrillation; Cardiac Output, Low; Chronic Disease; Digoxin; Diuretics; Dose-Response Relationship, Drug; Drug Interactions; Drug Therapy, Combination; Heart Failure; Humans; Mineralocorticoid Receptor Antagonists

Heart failure is a common disorder associated with significant morbidity, mortality and financial burden to health services. The pharmacotherapy of heart failure, including new treatments, will be discussed.

Topics: Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Cardiac Output, Low; Cardiotonic Agents; Defibrillators, Implantable; Digoxin; Humans; Mineralocorticoid Receptor Antagonists

Atrial fibrillation (AF) in heart failure develops commonly in older individuals and its prevalence increases as heart failure severity progresses. Because of deteriorating hemodynamics, patients with heart failure are at increased risk for developing AF and, conversely, AF in heart failure patients is associated with adverse hemodynamic changes. AF is believed to increase the mortality risk in heart failure, which may be minimized by treatment that includes the control of ventricular rate, prevention of thrombotic events, and conversion to normal sinus rhythm. Clinical guidelines recommend amiodarone or dofetilide in heart failure patients, but these drugs have certain drawbacks, such as an increased risk for bradyarrhythmias with amiodarone and proarrhythmic reaction with dofetilide. Some but not all clinical trials have suggested that rate control should be the primary therapeutic goal in high-risk heart failure patients with AF and, if unsuccessful, followed by rhythm control. The former is effectively achieved with rate-lowering beta-blockers alone or in combination with digoxin. Recent studies evaluating the effects of combination carvedilol/digoxin therapy demonstrate synergistic effects between the two drugs. This combination therapy decreased heart failure symptoms, effectively reduced ventricular rate, and improved ventricular function to a greater extent compared with that produced by either drug alone. Although digoxin alone is an effective heart failure treatment, its use as a single rate-control therapy is often ineffective in heart failure patients with AF associated with rapid ventricular response. Carvedilol is effective, alone or in combination, with digoxin in such heart failure patients with AF, and has been shown to reduce mortality risk in patients with chronic heart failure during prolonged therapy.

Topics: Adrenergic beta-Antagonists; Animals; Anti-Arrhythmia Agents; Atrial Fibrillation; Carbazoles; Cardiac Output, Low; Carvedilol; Digoxin; Disease Progression; Humans; Propanolamines; Randomized Controlled Trials as Topic

Topics: Adrenergic beta-Antagonists; Anti-Arrhythmia Agents; Cardiac Output, Low; Digoxin; Fibrinolytic Agents; Humans

The incidence and prevalence of heart failure is on the rise. It has become the single most expensive health care item in the United States and the number one discharge diagnosis in the elderly. The goals of therapy include both prevention and treatment of heart failure. In recent years research studies and randomized clinical trials have revolutionized the understanding of the pathophysiology and treatment of this disease. This article focuses on the medical management of chronic systolic heart failure based on the pathophysiology of the disease. Systolic heart failure is characterized by a decrease in left ventricular function and cardiac output, which results in activation of several neurohormonal compensatory systems. The long term effects of this neurohormonal activation leads to further deterioration of cardiac function. The use of hydralazine and nitrates to reduce the systemic vascular resistance was the first to show an improvement in mortality and morbidity. Then angiotensin converting enzyme inhibitors, by inhibiting the renin angiotensin system, demonstrated a greater improvement in mortality and morbidity. More recently the inhibition of the sympathetic stimulation with beta-blockers has been shown to have an additive effect on morbidity and mortality in combination with angiotensin-converting enzyme inhibitors. Digoxin and diuretics remain important for improving symptoms and decreasing hospitalizations but have not been shown to decrease mortality. The most recent advance in the treatment of cardiac failure is the demonstration that the aldosterone antagonists, spironolactone decreases morbidity and mortality.

Topics: Adrenergic beta-Antagonists; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Animals; Cardiac Output, Low; Cardiotonic Agents; Digoxin; Diuretics; Humans; Receptor, Angiotensin, Type 1; Receptor, Angiotensin, Type 2; Renal Replacement Therapy; Vasodilator Agents

Digitalis has been used for more than 250 years, but its role in the treatment of chronic heart failure has been intensively investigated only during the past two decades. Digoxin increases cardiac output both at rest and during exercise, alone or in combination with ACE inhibitors, and these hemodynamic effects are sustained during chronic therapy. A daily dose of digoxin that achieves a serum concentration of approximately 1.2 ng/ml is associated with a significant improvement in central hemodynamics, particularly in patients with impaired cardiac function despite pretreatment with diuretics and ACE inhibitors. Acute administration of digoxin in patients with chronic heart failure has an immediate sympathoinhibitory effect, and chronic therapy is associated with a sustained decrease in serum norepinephrine concentration. Discontinuation of digoxin in patients with chronic heart failure resulted in hemodynamic deterioration, which was reversed when the drug was readministered. Randomized withdrawal of digoxin in patients receiving only diuretics (PROVED study), or its withdrawal in patients receiving diuretics and ACE inhibitors (RADIANCE study), was associated with worsening of the clinical evidence of heart failure and a decrease in left ventricular systolic function in both studies. In the only large-scale, placebo-controlled mortality study reported thus for (DIG Trial), 7788 patients received standard drug treatment for chronic heart failure in addition to either digoxin or placebo. Digoxin had no impact on survival over the 37 months of follow-up, but the incidence of hospitalizations due to worsening heart failure was significantly reduced in patients receiving the drug compared with those receiving placebo.

Topics: Cardiac Output, Low; Cardiotonic Agents; Chronic Disease; Digoxin; Hemodynamics; Humans; Randomized Controlled Trials as Topic; Synaptic Transmission; Treatment Outcome

Topics: Animals; Cardiac Output, Low; Cardiotonic Agents; Digoxin; Enzyme Inhibitors; Humans; Muscle, Skeletal; Myocardium; Sodium-Potassium-Exchanging ATPase

Digoxin has been a controversial drug since its introduction >200 years ago. Although its efficacy in patients with heart failure and atrial fibrillation is clear, its value in patients with heart failure and sinus rhythm has often been questioned. In the 1980s, reports of some large-scale trials indicated that digoxin, with or without vasodilators or angiotensin-converting enzyme inhibitors, reduced signs and symptoms of congestive heart failure and improved exercise tolerance. This beneficial influence was mainly found in patients with more advanced heart failure and dilated ventricles, whereas the effect in those with mild disease appeared to be less pronounced. In the last few years, new data have shown that digoxin may also have clinical value in mild heart failure, either when used in combination with other drugs or when administered alone. As neurohumoral activation has increasingly been recognized to be a contributing factor in the disease progression of chronic heart failure, the modulating effects of digoxin on neurohumoral and autonomic status have received more attention. Also, there is evidence that relatively low doses of digoxin may be at least as effective as higher doses and have a lower incidence of side effects. Further, the recognition that the use of digoxin too early after myocardial infarction may be harmful and the development of other drugs, in particular angiotensin-converting enzyme inhibitors, have obviously changed the place of digoxin in the treatment of chronic heart failure. The large-scale survival trial by the Digitalis Investigators Group (DIG), whose preliminary results have recently been presented, has shown that although digoxin has a neutral effect on total mortality during long-term treatment, it reduces the number of hospital admissions and deaths due to worsening heart failure. The potentially new features of the old drug digoxin are discussed in this review.

Topics: Anti-Arrhythmia Agents; Cardiac Output, Low; Cardiotonic Agents; Digoxin; Heart Failure; Humans

Topics: Animals; Cardiac Output, Low; Cardiotonic Agents; Cause of Death; Contraindications; Digoxin; Humans; Myocardial Infarction; Practice Patterns, Physicians'

In the last 15 years several double-blind, placebo-controlled clinical trials have unequivocally shown that digitalis decreases symptoms of cardiac failure, results in a reduction in the need for hospitalization for treatment of congestive heart failure, and improves cardiac function. The major unresolved question concerning digitalis use is its safety. There are experimental data and clinical evidence that digitalis use may be associated with an increased mortality, particularly in the first year or two after an acute myocardial infarction. This increased mortality appears to be present even after adjustment for predictor covariants. This conclusion depends on the ability of statistical methods to account for differences in comorbidity. Since the question of digitalis safety remains after myocardial infarction, the physician should carefully examine the indications for administration of digitalis. More than the usual surveillance is required during chronic digitalis administration.

Topics: Cardiac Output, Low; Digoxin; Double-Blind Method; Heart; Heart Failure; Humans; Randomized Controlled Trials as Topic

Topics: Animals; Cardiac Output, Low; Digitalis Glycosides; Digitoxin; Digoxin; Dose-Response Relationship, Drug; Heart Rate; Humans; Muscle Contraction; Ouabain

Digoxin reduces hospitalizations due to heart failure (HF) and may also reduce mortality at low serum digoxin concentrations (SDC). Most HF patients are > or = 65 years, yet the effects of digoxin on outcomes in these patients have not been well studied.. Of the 7788 ambulatory chronic HF patients in normal sinus rhythm in the Digitalis Investigation Group trial (1991-1995), 5548 (2890 were > or = 65 years) were alive at 1 month and were either receiving placebo or had data on SDC. Of these patients, 982 had low (0.5-0.9 ng/mL) and 705 had high (> or = 1 ng/mL) SDC.. Among patients > or = 65 years, compared with 38% placebo patients, 34% low SDC patients died during 39 months of median follow-up (adjusted hazard ratio [AHR] = 0.81; 95% confidence interval [CI] = 0.68-0.96; p =.017). All-cause hospitalizations occurred in 70% of placebo and 68% of low-SDC patients (AHR = 0.86; 95% CI = 0.76-0.98; p =.019). Reduction in hospitalizations for HF occurred in both low and high SDC groups. High SDC was not independently associated with all-cause hospitalization or all-cause mortality. Age, impaired renal function, and pulmonary congestion reduced the odds of low SDC. Low-dose digoxin (< or = 0.125 mg/d) was the strongest independent predictor of low SDC (adjusted odd ratio = 2.37; 95% CI = 1.65-3.39); p <.0001).. Digoxin at low SDC was associated with a reduction in mortality and hospitalization in chronic geriatric HF, and low-dose digoxin was the strongest predictor of low SDC.

Topics: Age Factors; Aged; Canada; Cardiac Output, Low; Cardiotonic Agents; Chronic Disease; Creatinine; Digoxin; Diuretics; Female; Follow-Up Studies; Hospitalization; Humans; Male; Middle Aged; Placebos; Pulmonary Edema; Renal Insufficiency; Survival Rate; Treatment Outcome; United States

The association between serum digoxin concentration (SDC) and outcomes in women with heart failure (HF) has not been well studied.. To test the hypothesis that the effect of digoxin on outcomes in women with HF is bi-directional and dependent on SDC, as in men, and is modified by ejection fraction (EF).. We studied 1366 female participants of the Digitalis Investigation Group trial in whom data on SDC (ng/ml) were available. We calculated adjusted odds ratios (AOR) and Bonferroni-adjusted 97.5% confidence intervals (CI) for various outcomes at a median follow up of 41 months, in all women and stratified by EF 35%.. Compared with placebo (26.9%), 40.3% with SDC> or =1.2 (AOR=1.80; CI=1.14-2.86; p=0.004) and 26.6% with SDC 0.5-1.1 (AOR=1.05; CI=0.73-1.51; p=0.762) died. Respective rates for HF-hospitalizations were: placebo (32.8%), SDC> or =1.2 (38.0%) and SDC 0.5-1.1 (25.5%). For women with EF<35% (N=677), SDC 0.5-1.1 lowered odds for HF-hospitalizations (AOR=0.63; CI=0.39-1.00; p=0.026) without increasing odds for death (AOR=0.77; CI=0.47-1.26; p=0.233). In women with EF> or =35% (N=689), SDC 0.5-1.1 had a borderline association with death (AOR=1.58; CI=0.92-2.72; p=0.058) but not with HF-hospitalization (AOR=0.95; CI=0.54-1.66; p=0.826).. As in men, in women with HF, digoxin has a bi-directional effect based on SDC, and the beneficial effects were significant only among women with EF<35%.

Topics: Aged; Cardiac Output, Low; Cardiotonic Agents; Cause of Death; Chronic Disease; Digoxin; Female; Humans; Middle Aged; Placebos; Stroke Volume; Treatment Outcome

A randomized open-label clinical trial was conducted to determine whether mortality, readmission, or quality of life differed between heart failure patients managed with captopril plus diuretics and those with digoxin plus diuretics. A total of 345 heart failure patients in New York Heart Association functional classes 2 and 3 without atrial fibrillation, dyspnea of bronchopulmonary origin, or hypertension not controlled with diuretics was randomized for digoxin (n = 175) or captopril (n = 170) treatment and followed up for a median of 4.5 years. Socioeconomic, demographic, electrocardiographic, echocardiographic, spirometric, and chest radiograph data were obtained at the initial examination. In a random sample of half the patients, ergometric, echocardiographic, and Holter records were obtained at entry and at 3 and 18 months. Patients were followed up for > or = 3 years. The end points were mortality, hospitalization for cardiac events, deterioration in quality of life, worsening of functional class, and need for digoxin or captopril in the captopril and digoxin groups, respectively. The trial had to be terminated prematurely owing to the difficulty in finding candidates free of angiotensin-converting enzyme (ACE)-inhibitor treatment. Baseline patient characteristics were similar in both groups. From the clinical point of view, only the 48-month mortality was relevantly lower (20.9 vs. 31.9%, respectively) among patients treated with captopril than that in those receiving digoxin (log rank test, p = 0.07). No statistically or clinically relevant differences were found in other end points or adverse effects. The results suggest but do not confirm the hypothesis that captopril treatment in mild to moderate heart failure might provide better long-term survival than digoxin.

Topics: Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Captopril; Cardiac Output, Low; Cardiotonic Agents; Digoxin; Diuretics; Drug Therapy, Combination; Exercise Test; Female; Humans; Male; Middle Aged; Quality of Life; Spain; Survival Analysis; Ultrasonography

Digitalis has been used for more than 250 years, but its role in the treatment of chronic heart failure has been intensively investigated only during the past two decades. Digoxin increases cardiac output both at rest and during exercise, alone or in combination with ACE inhibitors, and these hemodynamic effects are sustained during chronic therapy. A daily dose of digoxin that achieves a serum concentration of approximately 1.2 ng/ml is associated with a significant improvement in central hemodynamics, particularly in patients with impaired cardiac function despite pretreatment with diuretics and ACE inhibitors. Acute administration of digoxin in patients with chronic heart failure has an immediate sympathoinhibitory effect, and chronic therapy is associated with a sustained decrease in serum norepinephrine concentration. Discontinuation of digoxin in patients with chronic heart failure resulted in hemodynamic deterioration, which was reversed when the drug was readministered. Randomized withdrawal of digoxin in patients receiving only diuretics (PROVED study), or its withdrawal in patients receiving diuretics and ACE inhibitors (RADIANCE study), was associated with worsening of the clinical evidence of heart failure and a decrease in left ventricular systolic function in both studies. In the only large-scale, placebo-controlled mortality study reported thus for (DIG Trial), 7788 patients received standard drug treatment for chronic heart failure in addition to either digoxin or placebo. Digoxin had no impact on survival over the 37 months of follow-up, but the incidence of hospitalizations due to worsening heart failure was significantly reduced in patients receiving the drug compared with those receiving placebo.

Topics: Cardiac Output, Low; Cardiotonic Agents; Chronic Disease; Digoxin; Hemodynamics; Humans; Randomized Controlled Trials as Topic; Synaptic Transmission; Treatment Outcome

To investigate the effects of prostaglandin E1 (PGE1) by intravenous drip in cor pulmonale patients with heart failure.. Thirty caseas of cor pulmonale with heart failure were treated with PGE1 at a dose of 200 micrograms.d-1 for 5 days and in 30 patients with cor pulmonale heart failure (no PGE1) and in 20 healthy subjects as controls. The level of serum endogenous digoxin-like factor (EDF), serum lipoid superoxide (LPO), serum superoxide dismutase (SOD) and blood PaO2, PaCO2 were determined. Their symptoms and signs were observed before and after treatment.. The level of serum EDF, LPO were significantly increased (P < 0.001) and serum SOD was significantly decreased (P < 0.001) in PGE1 group and controls group (no PGE1) as compared with healthy subjects. In PGE1 group the level of serum EDF, LPO were markedly decreased (P < 0.001), and serum SOD was markedly elevated (P < 0.001), and their symptoms, signs and blood gas parameters had noteworthyly improved (P < 0.01-0.001). But in the control group (no PGE1) the level of serum EDF, LPO, SOD, blood gas parameters and their symptoms and signs, showed no significant difference (P > 0.05).. PGE1 is effective in therapy of cor pulmonale with heart failure. Treatment with PGE1 shows more significant benefits in cor pulmonale patients with heart failure.

Topics: Aged; Alprostadil; Cardenolides; Cardiac Output, Low; Digoxin; Female; Humans; Lipid Peroxides; Male; Middle Aged; Pulmonary Heart Disease; Saponins; Superoxide Dismutase

Lisinopril, a long-acting, angiotensin-converting enzyme inhibitor, was compared with placebo in a randomized, parallel, double-blind, 12-week study of 193 patients with heart failure. All patients were New York Heart Association Functional Class II, III, or IV and had remained symptomatic despite optimal dosing with digoxin and diuretics. After 12 weeks of therapy, the improvement in treadmill exercise duration was greater in the lisinopril group (113 seconds) compared with the placebo group (86 seconds). This improvement in exercise duration was particularly evident in patients with left ventricular ejection fractions less than 35% (lisinopril = 130 seconds; placebo = 94 seconds). In patients receiving lisinopril, the increase in exercise duration was accompanied by an improvement in quality of life as measured by the Yale Scale Dyspnea/Fatigue Index and in signs and symptoms of heart failure. In addition, the lisinopril group had a larger mean increase (3.7%) in left ventricular ejection fraction when compared with the placebo group (1.3%). Thus, lisinopril, administered once daily for 12 weeks, was well tolerated and efficacious in the treatment of heart failure when used concomitantly with diuretics and digoxin.

Topics: Aged; Cardiac Output, Low; Cardiotonic Agents; Digoxin; Diuretics; Double-Blind Method; Drug Administration Schedule; Drug Therapy, Combination; Exercise Test; Female; Humans; Lisinopril; Male; Middle Aged; Quality of Life; Stroke Volume

There is increasing evidence that clinical deterioration in manifest chronic heart failure is related to both hemodynamic and neurohumoral factors. Only few data are available, however, on the progression of disease in its early stages, when treatment has not yet been initiated. The aim of this study was therefore to examine the changes in clinical and neurohumoral variables that occur over 6 months in patients with clinically stable and untreated heart failure, and to evaluate the influence of drugs that may affect these variables. Accordingly, we studied 64 patients with heart failure who were in New York Heart Association functional class II (88%) and III (12%). They were randomized to double-blind treatment with the oral dopamine agonist ibopamine (100 mg 3 times daily; n = 22), digoxin (0.25 mg once daily; n = 22) or placebo (n = 20). Their age (mean +/- SD) was 60 +/- 8 years, and left ventricular ejection fraction (mean +/- SD) was 0.33 +/- 0.08. Of the 64 patients, 56 (88%) completed the 6-month study period (p = NS between groups). Exercise time decreased in patients treated with placebo after 6 months (median -62 seconds; p < 0.05 vs baseline), but it increased with ibopamine (+48 seconds), and digoxin (+17 seconds; both p < 0.05 vs placebo). Plasma norepinephrine increased in the placebo group after 6 months (median + 31 pg/ml, p < 0.05 vs baseline), but decreased in patients receiving active drug treatment (ibopamine: -24 pg/ml, digoxin: -98 pg/ml, both p < 0.05 vs placebo). Plasma renin and aldosterone levels were unchanged after 6 months in the placebo group, but digoxin therapy slightly reduced plasma renin concentration (-5 microU/ml; p < 0.05 vs placebo).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adolescent; Adult; Aged; Cardiac Output, Low; Cardiotonic Agents; Deoxyepinephrine; Digoxin; Disease Progression; Dopamine Agonists; Double-Blind Method; Female; Follow-Up Studies; Humans; Male; Middle Aged; Netherlands; Neurotransmitter Agents; Norepinephrine; Physical Exertion; Placebos; Renin; Stroke Volume; Ventricular Function, Left

The safety and efficacy of angiotensin-converting enzyme inhibitors for very old patients with chronic heart failure have been less well documented than for younger patients.. A prospective, randomized double-blind, placebo-controlled study of captopril, 25 mg twice daily, was designed. Fifty patients (mean age 84.2 +/- 5.2) participated. The degree of chronic heart failure (according to the Boston Study Group rating), the distance walked in 6 minutes, and the occurrence of uncontrolled heart failure and adverse reactions were used as main outcome measures.. Significantly more patients receiving placebo developed uncontrolled heart failure than patients receiving captopril (p = .022). In an intention to treat analysis, the first and last evaluations of the degree of chronic heart failure were compared. A significantly different evolution was observed between the two treatment groups (p < .001), with a significant improvement only in the captopril-treated patients (p < .001). The distance walked in 6 minutes improved significantly only in the captopril group (p = .004). The only adverse reaction was rash in two patients receiving captopril.. The study gives further evidence that angiotensin-converting enzyme inhibitor treatment for very old patients with chronic heart failure is useful.

Topics: Aged; Aged, 80 and over; Captopril; Cardiac Output, Low; Chronic Disease; Digoxin; Double-Blind Method; Drug Tolerance; Exercise Tolerance; Female; Follow-Up Studies; Furosemide; Humans; Male; Placebos; Prospective Studies; Stroke Volume; Treatment Outcome; Ventricular Function, Left

The efficacy of captopril (capoten) and digoxin was comparatively studied in long-term randomized, double blind trials of 22 male patients with postinfarction cardiosclerosis, functional classes I-III and preserved sinus rhythm. The optimal doses of the drugs proved to be small (0.31 and 35 mg/day of digoxin and capoten, respectively). No adverse effects were noted. The mortality rate was 10 and 16.7% with digoxin and captopril, respectively. The drugs equally improved the functional class by 0.51 and 0.45 and VO2 max by 1.5 and 1.7 ml/min. Digoxin had a mild effect on heart rate (-8.4%) and ejection fraction (+5.7%) and deteriorated diastolic relaxation, by slowing down the early peak of transmitral Doppler spectrum by 16.2%. Captopril significantly improved diastolic function by increasing the early peak by 17.2%. No significant changes in left ventricular sizes were recorded. The clinical efficacy of captopril was explained by a significant decrease in angiotension II (70%) and norepinephrine (40%) levels and by associated normalization of baroreflex regulation. Digoxin insignificantly affected the levels of angiotensin II and norepinephrine, but improved the baroreceptor regulation of sympathetic control impaired in chronic heart failure. It is concluded that extracardiac mechanisms play a major role in the action of not only captopril, but digoxin in the treatment of patients with postinfarct cardiosclerosis and chronic heart failure with sinus rhythm.

Topics: Adult; Aged; Angiotensin II; Baroreflex; Captopril; Cardiac Output, Low; Chronic Disease; Digoxin; Double-Blind Method; Heart Rate; Humans; Male; Middle Aged; Myocardial Infarction; Myocardium; Norepinephrine; Sclerosis; Stroke Volume; Time Factors

Xamoterol, 200 mg b.d. was compared with digoxin 0.125 mg b.d. or t.d. in a 3-month double-blind trial in 178 patients with mild to moderate heart failure. Xamoterol and digoxin both significantly increased exercise duration, but greater changes were observed with xamoterol. Xamoterol also improved quality of life to a greater degree than digoxin, and was better tolerated.

Topics: Adrenergic beta-Agonists; Cardiac Output, Low; Digoxin; Double-Blind Method; Drug Evaluation; Humans; Middle Aged; Multicenter Studies as Topic; Physical Exertion; Propanolamines; Xamoterol

A randomised, double blind, placebo controlled, crossover study of digoxin withdrawal and reintroduction was carried out over two periods of eight weeks each after long term treatment. Forty four patients with stable heart failure in sinus rhythm and plasma digoxin concentrations over 0.8 ng/ml were studied. Their progress was assessed by clinical criteria, by haemodynamic measurements (systolic time intervals and echocardiography), and by pharmacological measurements of erythrocytic sodium pump numbers and activity. After withdrawal of digoxin clinical deterioration occurred in only 25% of the patients. Furthermore, in only 9% of cases was digoxin reintroduction thought to be necessary. There was deterioration in only 11% of the patients during digoxin treatment. Deterioration during digoxin withdrawal was accompanied by changes in systolic time intervals, but similar, albeit smaller changes in systolic time intervals also occurred in patients with no deterioration. Deterioration was accompanied by changes in the pharmacological effects of digoxin on the erythrocytes, consistent with a loss of effect, and these changes did not occur in those who did not deteriorate. The occurrence of deterioration could not be predicted by any clinical, haemodynamic, or pharmacological measurements made before withdrawal.

Topics: Adult; Aged; Cardiac Output, Low; Clinical Trials as Topic; Digoxin; Double-Blind Method; Drug Administration Schedule; Female; Hemodynamics; Humans; Long-Term Care; Male; Middle Aged; Random Allocation; Systole

In 10 patients with postoperative cardiac dysfunction which required dopamine for inotropic and hemodynamic support, we observed the cardiovascular effects of short-term digoxin administration. The average dosage of dopamine was 7.45 micrograms/kg per minute and was maintained while the patients were given 1 mg of digoxin over 8 hours. The dosage of dopamine was then tapered over the next 4 hours. We observed a significant increase in the cardiac index (4 hours) and a reduction in the heart rate (8 hours) before the dopamine dosage was reduced. After a reduction in dopamine dosage to 2.28 micrograms/kg per minute, these effects persisted. No significant changes were noted in systemic vascular resistance or pulmonary artery diastolic pressure during digoxin administration. These results indicate that the inotropic effects of dopamine and digoxin are additive when given in combination and that digoxin can be used to significantly reduce the dopamine dosage in patients with postoperative cardiac failure. Thus, the combination of an acute inotropic agent, dopamine, and a chronic inotropic agent, digoxin, appears to be clinically useful in postoperative cardiac dysfunction.

Topics: Cardiac Output; Cardiac Output, Low; Clinical Trials as Topic; Coronary Disease; Digoxin; Dopamine; Drug Therapy, Combination; Female; Heart Rate; Hemodynamics; Humans; Male; Middle Aged; Postoperative Care; Prospective Studies

Over 80% of all heart failure patients are 65 years and older. The diagnosis and management of heart failure in older adults can be challenging. However, with the correct clinical skill and experience, most geriatric heart failure can be properly diagnosed and managed. Management of geriatric heart failure can be simplified by following this useful mnemonic: DEFEAT Heart Failure. This covers the essential aspects of geriatric heart failure management: Diagnosis, Etiology, Fluid, Ejection fraAction, and Treatment. The process begins with a clinical Diagnosis, which must be established, before ordering an echocardiogram, as nearly half of all geriatric heart failure patients have normal left ventricular ejection fraction. Because heart failure is a syndrome and not a disease, an underlying Etiology must be sought and determined. Determination of the Fluid volume status by careful examination of the external jugular veins in the neck is vital to achieve euvolemia. An echocardiography should be ordered to obtain left ventricular Ejection frAction to assess prognosis and guide Therapy. However, if left ventricular ejection fraction cannot be determined, as in many developing nations, all geriatric heart failure patients should be treated as if they have low ejection fraction, and should be prescribed an angiotensin-converting enzyme inhibitor and a beta-blocker. Diuretic and digoxin should be prescribed for all symptomatic patients with heart failure. An aldosterone antagonist may be used in select patients with advanced systolic heart failure, carefully avoiding hyperkalemia.

Topics: Adrenergic beta-Antagonists; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Body Fluids; Cardiac Output, Low; Digoxin; Diuretics; Echocardiography; Family Practice; Female; Heart Failure; Humans; Male; Stroke Volume; Vasodilator Agents

Carbohydrate antigen 125, known as a marker for ovarian cancer, has been reported to be elevated in heart failure caused by left ventricular dysfunction. A case of elevated carbohydrate antigen 125 in isolated right heart failure due to atrial septal defect with preserved left ventricular function is reported.

Topics: Aged; Ascites; CA-125 Antigen; Cardiac Output, Low; Cardiotonic Agents; Digoxin; Diuretics; Female; Heart Septal Defects, Atrial; Humans; Ultrasonography

Topics: Cardiac Output, Low; Cardiotonic Agents; Digoxin; Female; Humans; Male; Sex Factors; Treatment Outcome

The aim of the present study was to describe patients considered to have had heart failure (HF), or were being treated for HF, in a defined area in primary health care, e.g. diagnostic procedures, aetiologic diseases and management, and to evaluate whether there is a difference between the genders.. Descriptive retrospective investigation.. Atvidaberg community situated in southeast Sweden, 12 400 inhabitants.. 256 patients treated for symptomatic HF.. Prevalence, aetiology, diagnostic procedures and management of HF and differences between the genders.. The diagnosis of HF was based on an objective evaluation of cardiac function in only 31% of the patients. Ischaemic heart disease (IHD) was the predominant associated disease, followed by hypertension. Therapy included diuretics (84%), angiotensin converting enzyme (ACE) inhibitors (56%) and digoxin (40%). Only 52% had optimal doses of ACE inhibitors. Women had a significantly higher mean age and their diagnoses were based on an objective diagnostic test (echocardiography) in only 20%. Women were prescribed ACE inhibitors to a lesser extent (43%) than men (64%) and with a lower optimal dose (44% versus 56% in men).. There is still room for improvement in the management of HF in primary health care, especially in women, where the diagnosis is not generally based on an objective evaluation of cardiac function and where the treatment to a lesser extent than in men includes ACE inhibitors.

Topics: Adult; Age Distribution; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Cardiac Output, Low; Digoxin; Diuretics; Electrocardiography; Female; Humans; Hypertension; Male; Middle Aged; Myocardial Ischemia; Primary Health Care; Retrospective Studies; Sex Distribution; Sweden; Women's Health

The effects of digitalis on the baroreflexes in human chronic heart failure have been well studied. Similarly, since it has been recently shown that chemoregulation remains generally effective during cardiac failure, the goal of this study was to evaluate the effects of a chronic administration of digoxin on the chemoreflexes. Hemodynamic and blood gas parameters were assessed in 7 patients with chronic congestive heart failure before and after chronic administration for 10 days of digoxin therapy (0.25 mg daily). In both situations measurements were performed 1/ in baseline conditions at room air and, 2/ after inhalation of pure O2 for 30 min, in order to inhibit the activation of the chemoreflexes. At room air, acute O2 inhalation resulted in a significant decrease in heart rate and cardiac output. After digoxin therapy, comparatively to pre-treatment values, cardiac output, stroke volume and PaO2 were significantly higher while heart rate, systemic resistance and pulmonary wedge pressure were lower. Furthermore, acute O2 inhalation did not modify heart rate or any hemodynamic variables. These results suggest that after digoxin therapy chemoreflex was no more activated in these patients. This effect may be related to the sympatho-inhibitory and to the positive inotropic effects of digoxin: improving hemodynamic and blood gas parameters may result in the inactivation of the reflex.

Topics: Aged; Blood Gas Analysis; Cardiac Output, Low; Cardiotonic Agents; Chemoreceptor Cells; Digoxin; Hemodynamics; Humans; Male; Middle Aged; Oxygen; Reflex

Topics: Cardiac Output, Low; Cardiotonic Agents; Diastole; Digoxin; Humans

Topics: Adrenergic beta-Antagonists; Aged; Angiotensin-Converting Enzyme Inhibitors; Anti-Arrhythmia Agents; Atrial Fibrillation; Calcium Channel Blockers; Cardiac Output, Low; Digoxin; Evidence-Based Medicine; Frail Elderly; Health Services for the Aged; Humans; Medical History Taking; Monitoring, Physiologic; Outcome and Process Assessment, Health Care; Patient Education as Topic; Physical Examination; Stroke Volume

Topics: Aged; Arrhythmias, Cardiac; Cardiac Output, Low; Digoxin; Diuretics; Emergencies; Furosemide; Humans; Male; Potassium

Cardiac involvement rarely occurs in classic hemolytic uremic syndrome (HUS); it is often fatal.. The first patient, a 21-month-old boy, developed classic HUS with acute renal failure. Peritoneal dialysis was performed for 20 days. On the 10th day of dialysis, myocardial infarction occurred, probably related to coronary thrombus. The patient was given heparin and antibiotics because of an unexplained fever. The outcome was favorable despite antero-apical cardiac necrosis, and moderated chronic renal failure. The second patient, a 24-month-old girl, also showed a classic HUS, which required peritoneal dialysis for 10 days. Dilated cardiomyopathy with cardiac failure appeared on the 4th day of dialysis, not related to the volume overload and metabolic consequences of the acute renal failure, such as systemic hypertension or ineffective dialysis. On the 5th day of dialysis neurological involvement appeared. Neurological, cardiac and renal outcome was favorable. The third patient, a 25-month-old girl, developed a classical HUS, requiring peritoneal dialysis for 25 days. No cardiac insult appeared during the acute phase of the disease. After dialysis, the child had chronic renal failure (creatinine clearance: 15 mL/min/1.73 m2). Dilated cardiomyopathy appeared 3 months later, without definite etiology. The outcome was favorable with digoxin treatment.. A cardiac involvement should also be searched for in the acute phase of HUS and several months later.

Topics: Acute Kidney Injury; Cardiac Output, Low; Cardiomyopathy, Dilated; Cardiotonic Agents; Creatinine; Digoxin; Female; Follow-Up Studies; Hemolytic-Uremic Syndrome; Humans; Infant; Kidney Failure, Chronic; Male; Myocardial Infarction; Peritoneal Dialysis; Psychomotor Agitation; Sleep Stages; Treatment Outcome

We report a case of a 33 yr old woman with pulmonary hypertension secondary to uncorrected right coronary artery to pulmonary artery fistula who underwent two successful operative deliveries under general anesthesia.. This woman underwent an emergency Caesarean section at 32 wk gestation because she presented in NYHA Class IV, heart failure and premature labour. She did not have antenatal follow-up. For her second pregnancy, she was managed from the first trimester of pregnancy by the cardiologist, obstetrician and anesthesiologist. She received oral furosemide and digoxin from eight weeks gestation. Pregnancy was managed to term before she progressed to NYHA Class IV and cardiac failure at 37 wk gestation. She had a Caesarean section under general anesthesia. She received rapid sequence induction of anesthesia and tracheal intubation with 0.1 mg x kg(-1) etomidate, 2 mg x kg(-1) succinylcholine and maintenance with nitrous oxide 50% in oxygen, isoflurane 1% and 0.1 mg x kg(-1) vecuronium. Fentanyl, 2 microg x kg(-1) helped to obtund the hypertensive response to intubation. Analgesia was provided with 1 mg x kg(-1) morphine. Glyceryl trinitrate infusion, 10-30 microg x min(-1) was used in addition to the anti-heart failure therapy. End-tidal capnography, electrocardiogram, pulse oximetry, continuous arterial blood pressure and pulmonary arterial catheter provided hemodynamic monitoring. The lungs were mechanically ventilated for 24 hr postoperatively. She received anti-heart failure therapy which she continued after discharge. She was NYHA class II upon discharge. She defaulted from further follow-up.. Although the literature advocates, in this situation, controlled vaginal delivery utilising epidural analgesia, we describe the successful outcome for operative delivery under general anesthesia in a patient with secondary pulmonary hypertension and heart failure.

Topics: Adult; Analgesics, Opioid; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthesia, Obstetrical; Arterio-Arterial Fistula; Blood Pressure; Cardiac Output, Low; Cardiotonic Agents; Cesarean Section; Coronary Vessel Anomalies; Digoxin; Diuretics; Female; Furosemide; Humans; Hypertension, Pulmonary; Intubation, Intratracheal; Morphine; Neuromuscular Blockade; Nitroglycerin; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Artery; Respiration, Artificial; Vasodilator Agents

Development of guidelines can be a difficult process; each organization or institution must establish the rules and criteria for including specific therapies and the level of complexity needed. Specific outcomes must be incorporated, including maintenance of comfort and functionality, freedom from hospitalization, and survival. In existing guidelines for the management of heart failure, angiotensin-converting enzyme (ACE) inhibitor therapy is clearly the gold standard. However, there is still a high mortality with ACE inhibitor therapy; the key may be choosing the right patients. Current guidelines reflect the uncertainty regarding digoxin before the Digitalis Investigation Group (DIG) trial; obviously, these guidelines should be revisited. Clinical practice guidelines for the management of heart failure need to be revised to include a better consensus on beta-blockade, the new data on digoxin, emerging data on angiotensin II receptor antagonists, and current thinking on anticoagulant therapy.

Topics: American Heart Association; Angiotensin-Converting Enzyme Inhibitors; Cardiac Output, Low; Cardiotonic Agents; Digoxin; Humans; Outcome Assessment, Health Care; Placebos; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; United States; United States Agency for Healthcare Research and Quality

From an economic, mortality, and functional standpoint, heart failure is clearly a disease that needs to be targeted. We can develop a model for heart failure to determine the impact that specific management strategies will have on the overall cost to the system, which by itself can tell us some interesting things because we're currently spending twice as much on transplantation as on digoxin therapy. We can then use this model to assess the impact of different strategies, such as greater use of angiotensin-converting enzyme (ACE) inhibitors or digoxin therapy.

Topics: Angiotensin-Converting Enzyme Inhibitors; Cardiac Output, Low; Cardiology Service, Hospital; Cost of Illness; Cost Savings; Digoxin; Diuretics; Emergency Treatment; Heart; Heart Transplantation; Humans; Office Visits; Quality of Life; United States

To determine the prevalence of digoxin use as well as its indications in elderly patients at the time of admission to a geriatric unit of a general hospital.. One hundred and thirty elderly patients aged 65 and over (mean age = 80 +/- 9 years), 100 women and 30 men were consecutively investigated. Each patient was submitted to a thorough clinical investigation, laboratory work-up, chest X-ray, electrocardiogram and doppler echocardiogram. The use of digoxin was considered appropriate, questionable or inappropriate.. At the time of admission to the geriatric unit 27.6% of the patients were receiving digoxin. The indication was considered appropriate in 36.1%, questionable in 11.1% and inappropriate in 52.7%.. We found a high prevalence of digoxin use in elderly patients admitted to a geriatric unit of a general hospital. In most cases its indications were considered inappropriate or questionable. Due to the increased risk of digitalis intoxication in this age group the drug should be prescribed under more strict indications.

Topics: Age Factors; Aged; Aged, 80 and over; Cardiac Output, Low; Cardiotonic Agents; Digoxin; Drug Prescriptions; Female; Hospitals; Humans; Male

To review the Agency for Health Care Policy and Research (AHCPR) clinical practice guideline for heart failure and comment on the guideline regarding pharmacotherapy from the perspective of the latest clinical trial data and the authors' clinical experience.. A MEDLINE search (1966 to June 1997) of English-language literature pertaining to the pharmacotherapy of heart failure was performed. Special emphasis was placed on literature published in the last 5 years. Additional literature was obtained from reference lists of key articles identified through the search.. Pertinent clinical trials were reviewed and considered along with information from the authors' database of over 800 patients with heart failure. Evidence concerning the use of angiotensin-converting enzyme inhibitors at appropriate dosages in all New York Heart Association classes of heart failure and the inclusion of digoxin as part of triple therapy in all symptomatic patients with left ventricular systolic dysfunction are reviewed. Strategies to circumvent clinical problems that may limit the proper application of standard therapeutic agents are considered, and the possible future role of beta-blockers as the therapeutic agents in patients with heart failure is discussed.. The AHCPR guideline provides the clinician with an excellent framework for treating the patient with heart failure. Building on the fundamentals of the guideline, the clinician can carefully apply current therapy at appropriate dosages and in the best combinations to individualize and thereby optimize pharmacologic therapy for this patient population.

Topics: Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Calcium Channel Blockers; Cardiac Output, Low; Digoxin; Diuretics; Female; Heart Failure; Humans; Hydralazine; Isosorbide Dinitrate; Male; Ventricular Dysfunction, Left

Measurement of serum digoxin concentration is recommended as a routine in patients undergoing digoxin therapy because its therapeutic range is narrow. The presence of a high concentration of digoxin-like immunoreactive substances(DLIS) in human serum have been reported in a number of pathophysiological conditions. DLIS which cross-react with anti-digoxin antibodies, can falsely elevate the total digoxin concentration and is troublesome in the therapeutic monitoring of digoxin. The concentrations of serum total digoxin and DLIS in twelve patients of cardiac failure with renal insufficiency were estimated after determination of free digoxin by ultrafiltration with fluorescence polarization immunoassay. In these patients, the free digoxin concentration in serum determined was 0.79 +/- 0.48 (0.46-2.10) nmol.L-1. The total digoxin determined(1.31 +/- 0.80 nmol.L-1) was significantly higher than the calculated total digoxin(1.05 +/- 0.64 nmol.L-1) (P < 0.01), suggesting the presence of elevated DLIS in serum for these patients. The calculated DLIS concentration was 0.27 +/- 0.19(0.07-0.76) nmol.L-1. The results were well consistent with that obtained by recently published method of Dasgupta et al. In conclusion, the approach presented in this paper can estimate the true serum concentrations of digoxin and DLIS in patients of chronic cardiac failure with renal insufficiency.

Topics: Cardenolides; Cardiac Output, Low; Digoxin; Fluorescence Polarization Immunoassay; Humans; Kidney Failure, Chronic; Saponins; Ultrafiltration

Topics: Arrhythmia, Sinus; Cardiac Output, Low; Digoxin; Humans

Presented is a case story of a patient with highly elevated serum levels of the tumour marker CA 125 (Cancer Antigen 125). The patient was thought to have ovarian cancer, but eventually the source of the elevated serum CA 125 levels became clear: cardiac failure caused by thyrotoxicosis. Benign and malignant causes of elevated serum levels of CA 125 are described briefly.

Topics: Aged; Aged, 80 and over; Antigens, Tumor-Associated, Carbohydrate; Ascites; Cardiac Output, Low; Coagulants; Diagnosis, Differential; Diet, Sodium-Restricted; Digoxin; Diuretics; Female; Humans; Thyrotoxicosis; Thyrotropin; Thyroxine

The clinicopathologic features of a patient with primary carcinoid tumor of the ovary who presented with the signs of cardiac failure are described. The patient underwent total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + bilateral pelvic lymphadenectomy + appendectomy; and she is alive with no evidence of recurrent disease one year after surgery.

Topics: Appendectomy; Carcinoid Tumor; Cardiac Output, Low; Dermoid Cyst; Digoxin; Fallopian Tubes; Female; Furosemide; Humans; Hysterectomy; Lymph Node Excision; Middle Aged; Neoplasms, Multiple Primary; Ovarian Neoplasms; Ovariectomy

Topics: Cardiac Output, Low; Digoxin; Humans

Fourteen mothers were treated with flecainide for fetal atrial tachycardias associated with intrauterine cardiac failure. Twelve of the 14 fetuses responded by conversion to sinus rhythm. One of the 12 fetuses subsequently died in utero. The remaining fetuses suffered no morbidity and were alive and well 3 months to 2 years after delivery. The two fetuses in whom atrial tachycardia did not convert with flecainide were successfully treated with digoxin. These results compare favourably with previous forms of antiarrhythmic treatment. After recent reports of the side effects of flecainide treatment, however, it has been advised that this drug should be confined to high risk patients and those with life threatening arrhythmias. The use of flecainide for fetal arrhythmias should be limited to patients with severe fetal hydrops and supraventricular tachycardias. It should not be the first drug of choice in atrial flutter.

Topics: Cardiac Output, Low; Digoxin; Female; Fetal Death; Fetal Diseases; Flecainide; Humans; Pregnancy; Tachycardia

Cardiac beta-adrenoceptors and the positive inotropic effects of adenylate cyclase-dependent (dobutamine, histamine, forskolin) and adenylate cyclase-independent agents (isobutylmethylxanthine (IBMX), dibutyryl-cAMP (db-cAMP), digoxin, digitoxin and calcium were measured in papillary muscle strips from severely failing (NYHA IV), moderately failing (NYHA II-III) and non-failing (NYHA I) human hearts. The density of beta-adrenoceptors in three NYHA I patients were 40.0, 42.0 and 42.9 fmol mg-1 protein. The density of cardiac beta-adrenoceptors was significantly reduced in NYHA II-III to 18.0 +/- 1.1 fmol mg-1 protein (n = 16) and further reduced in NYHA IV to 9.5 +/- 1.6 fmol mg-1 protein (n = 7). The KD values did not differ between the groups. Correspondingly, the positive inotropic effect of dobutamine was significantly reduced in NYHA II-III and almost lost in NYHA IV. The positive inotropic effect of histamine was similar in non-failing and moderately failing myocardium but reduced in preparations from severely failing hearts (NYHA IV). The positive inotropic effect of IBMX was diminished in moderately and severely failing myocardium depending on the functional class of heart failure. In contrast, the effects of forskolin, db-cAMP, digoxin and digitoxin were not impaired in NYHA IV when compared with the maximal positive inotropic effect of calcium. It is concluded that in the failing human heart (a) the number of cardiac beta-adrenoceptors is reduced proportional to the severity of heart failure; (b) the receptor coupling of H2-receptors to adenylate cyclase may be impaired, but only in severe heart failure; (c) the basal cAMP formation may be diminished; and that (d) the catalytic subunit of the adenylate cyclase and the cAMP-dependent protein kinases may be promising targets for drugs to restore force of contraction in human heart failure.

Topics: 1-Methyl-3-isobutylxanthine; Adult; Bucladesine; Calcium; Cardiac Output, Low; Cardiotonic Agents; Colforsin; Digitoxin; Digoxin; Dobutamine; Histamine; Humans; In Vitro Techniques; Middle Aged; Myocardial Contraction; Myocardium; Receptors, Adrenergic, beta; Stimulation, Chemical

We have introduced enalapril, in doses equal to or less than the 2.5 mg currently recommended, as an adjuvant to digoxin and diuretics in 17 patients of mean (SD) age 83 (5) years with severe heart failure. Only eleven patients tolerated its introduction. Unlike those reported in younger patients, all but one of the adverse drug reactions occurred 8 h or more after the first dose. Aged patients started on ACE inhibitors should be observed in hospital until stabilized on a maintenance dose. Three patients had an adverse reaction which differed in nature from those previously reported: acute confusional state, ataxia and mesenteric ischaemia. Ten patients were discharged on 5 mg or 10 mg maintenance doses of enalapril. In nine of them improvement on triple therapy was sustained for a minimum of three months. ACE inhibition was lost in the other patient when her compliance with enalapril therapy fell to around 75%: monitoring compliance is essential when ACE inhibitors are used in low dosages. Enalapril was withdrawn during follow up in three patients because of symptoms of mesenteric ischaemia and in four because of dramatic deterioration of renal function. One of the latter was found subsequently to have severe bilateral atheromatous renal artery stenosis. When isosorbide dinitrate was substituted for enalapril, symptoms of mesenteric ischaemia resolved and renal function returned to baseline. Continuing surveillance for adverse effects is essential in patients of this age group with severe heart failure, and the risk of occult renal artery stenosis requires regular biochemical screening during follow up.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Aged, 80 and over; Cardiac Output, Low; Digoxin; Drug Therapy, Combination; Electrocardiography; Enalapril; Exercise Test; Female; Furosemide; Humans; Male; Patient Compliance; Peptidyl-Dipeptidase A; Time Factors

The efficiency of digoxin in elderly and old patients with subacute myocardial infarction is dependent on the original disorders of left-ventricular systolic phase structure. Changes in systolic phase structural parameters in the presence of supporting digoxin therapy show correspondence to changes of these parameters in response to a single digoxin dose. Digoxin's positive inotropic effect was similar in patients with the sinus rhythm and those with atrial fibrillation. The positive inotropic action of digoxin is not associated with a negative chronotropic effect in patients with sinus rhythm and normal heart rate.

Topics: Aged; Cardiac Output; Cardiac Output, Low; Digoxin; Heart Failure; Heart Ventricles; Humans; Middle Aged; Myocardial Infarction; Systole

Topics: Cardiac Output, Low; Digoxin; Female; Heart Rate; Hemodynamics; Humans; Male; Middle Aged; Myocardial Contraction; Pituitary Hormones; Thyroid Hormones

Topics: Adult; Aged; Cardiac Catheterization; Cardiac Output, Low; Digoxin; Female; Heart Function Tests; Hemodynamics; Humans; Hypertension; Male; Middle Aged; Prazosin; Vascular Resistance