Use of digoxin in heart failure due to systolic dysfunction
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Digitalis has been used for over 200 years to treat patients with heart failure (HF). Evidence from clinical trials supports the use of digoxin (the most widely used formulation of digitalis) in patients with HF due to left ventricular systolic dysfunction, particularly in patients with more advanced symptoms . However, there is no evidence that digoxin improves survival.
The effects of digoxin on hemodynamics, exercise tolerance, and symptoms in patients with HF and use of digoxin in HF will be reviewed here. The use of digoxin in the management of HF should be considered in the context of comprehensive medical therapy of HF with a reduced LVEF (figure 1) . (See "Overview of the therapy of heart failure with reduced ejection fraction".)
MECHANISM OF ACTION
Digitalis acts by inhibiting the Na-K-ATPase pump in myocardial cells . Increased intracellular sodium promotes sodium-calcium exchange, leading to a rise in the intracellular calcium concentration. This results in improved isolated myocyte contractile performance (increased shortening velocity) and overall left ventricular (LV) systolic function [3,4].
Digitalis also exerts an antiadrenergic action in patients with heart failure (HF) by inhibiting sympathetic outflow and augmenting parasympathetic tone. These actions may contribute to the clinical utility of digitalis in some patients.
Digitalis can also be beneficial in patients with HF due to systolic dysfunction with atrial fibrillation (AF) with rapid ventricular response , though other agents are preferred for rate control. For patients with compensated systolic HF and AF, a beta blocker (with or without adjunctive digoxin) is generally preferred for rate control. Digitalis slows the ventricular rate during AF, largely via increased parasympathetic tone. Through both rate control and improved contractility, digitalis relieves symptoms of systolic HF when associated with AF and a rapid ventricular rate. (See "Control of ventricular rate in atrial fibrillation: Pharmacologic therapy" and "The management of atrial fibrillation in patients with heart failure".)
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- MECHANISM OF ACTION
- Short-term hemodynamic effects
- EFFICACY OF CHRONIC THERAPY
- Trials of digoxin withdrawal
- DIG trial and patient survival
- - Effect in women
- Physiologic effects
- - Exercise performance
- - Neurohumoral activation
- OPTIMAL DIGOXIN LEVEL
- MAJOR SOCIETY GUIDELINES
- SAFETY AND MONITORING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS