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Posts Tagged ‘digoxin’

 

It was delicate few minutes  in one of  my recent  visits to a corporate hospital , when I noticed an emergency physician  hesitated to follow my advice to  prescribe IV Digoxin for a patient with  Atrial fibrillation and fast ventricular rate.His fear was, his consultant, a modern day cardiologist wouldn’t like it as Amiodarone has become a default drug for atrial fibrillation in that Institution. I could sense. . .he felt so out of place to take on my suggestion.

I reminded the young physician , the uniqueness  of  Digoxin and its  un-diminished value for this particular indication ,still he was reluctant and didn’t oblige.

I realised , it was my mistake to expect  a place for the humble fox glove in corporate crash-carts of centrally climate controlled  cardiology suits !

“Medicine need to be practiced   not only with best science(Truth) but also in a holistic and  cost efficient manner . There is no place for glamor, glitter  and commerce in your prescriptions !  In near future , teaching Medicine to students would  essentially  become  “more of moral” than “science” .

Reference

Link -Which is the best combination for rate control in Atrial fibrillation

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Digoxin is a wonder cardiology drug used for more than a century.We know the pioneering efforts  of  William withering  in detecting the potential  of the unknown  herb  Foxglove.

Mechanism of action

The beneficial effects of Digoxin is attributable  to

  • Positive inotropic  action
  • Vagal action

Digoxin blocks the sodium potassium ATPase in the  myocyte cell membrane .

This cause accumulation of NA + ions within the cells. The excess  Na , then   facilitates  the Na -Ca exchange port .

This pumps in more calcium   into the myocyte.

Increased  calcium means more forceful contraction and that is positive inotropism* .

* This is a  highly simplified version of   Digoxin’s action . It should  be remembered  simple availability of excess calcium can not guarantee  contractility,   as it requires adequate number  of receptors.

Digoxin  is used in which type of cardiac failure  ?

Digoxin is used for both for LV and  biventricular  failure .

Digoxins is still  often  in isolated RV failure  of any cause (Cor pumonale, PPH, Eisenmenger etc)


Digoxin and RV dysfunction

Digoxin  has a tendency  to  hit the atrial muscles  at random causing  multiple short circuiting (Micro reentry )   forming  a perfect nidus  for complex atrial arrhythmias  including MAT .The coexisting    hypoxia  (which is all the more common here )  aggravates the problem .

Inotropism of RV : Does it really exist ?

It is often quoted , RV is a passive pump. It does not mean inotrpism is an exclusive property of LV.

RV has to generate about 30mmhg to pump the blood into  the lungs.

In cor-pulmonale the RV works against an afterload of around 50-70 mmhg  , making  RV inotropism  much more important  concept.

Rate control in atrial fibrillation Digoxin lowers the heart rate by vago mimetic action ,  primarily in  AV node  and to a  certain  extent in SA node .Ventricular rate reduction  is the prime requirement  in the management  atrial fibrillation and this property  is still the crowing  glory of  Digoxin.

Though beta blockers and  verapamil  can be used as rate controlling agent ,  lack of negative  inotropism makes  digoxin    prevail   over , especially in severely dysfunctional  ventricle .

But , one disadvantage of Digoxin is , since it requires  a vagal traffic to mediate it ‘ s rate controlling effect , it  is less effective ,  when there is  high sympathetic activity as during exercise.

What is the action of digoxin on interventricular  septal contraction ?

Digoxin , simply does not know where it acts when administered in cor pulmonale  ! We believe in cor-pulmonale the maximum action would be the area of maximum dysfunction .This is purely  an assumption. In cor -pulmonale septum shifts it’s loyalty from LV to RV as the later is the distressed chamber.So , logic would be there  is a theoretical  compromise of LV function in  patients with cor -pulmonale. These factors make  the   inter ventricular  interaction and dependence a complex one.

Some believe  the improvement of sub clinical LV dysfunction in cor pulmonale may be more important factor in giving relief  to  the patient’s  symptom.

What are the other RV inotropes ?

Doubtamine has some RV inotropy  .This again may be due to a spill over effect from LV rather than a primary RV inotropism .

As such , there is no great breakthrough  in creating a powerful isolated RV  isolated RV inotropic dug.

Probably  the best way to  give relief to RV is to reduce the pulmonary artery pressure as invariably sever PAH  is the predominate  accompaniment

(Nitric oxide ,  Epo prostenol etc)

Final message

  • Digoxin , indeed has  some useful  role in cor- pulmonale .
  • But ,the benefits are more pronounced in late stages of RV failure.
  • Since the dose required to get an optimal RV inotropy is high the safety margin  is reduced.
  • Since there is a propensity   for complex atrial  arrhythmias  ,  it has to be used very cautiously in management  of   atrial fibrillation due to cor pulmonale .(Than in other forms of AF)

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Ectopic beats , other wise called premature depolarisaton are one of the common ECG abnormalities  diagnosed by physicians.

  • Atrial premature beats (APDs)
  • Ventricular premature beats(VPDs) 

APDs and VPDs  form  the bulk of all clinically important ectopic beats.

Heart has a specialised electrical conducting system , every cell in this system is capable of firing on it’s own. But why then only the atrium and ventricle produce ectopic beats .Other structures like AV node, His bundle , purkinje are relatively rare to produce ectopic beats .

Is the AV junction relatively immune to develop JPDs?

The answer to this question would be  “May be yes” . Yet, we need to recognise they may not be as rare as we think , many times we fail to  diagnose  it or rather recognise it !

Certain observation about Junctional premature depolarisation are made .AV junction has unique properties than any other parts of the heart.The basic purpose of AV junction ( AV node is not a preferred word as it has no anatomically distinct demarcation)  is to apply a electrical break on the incoming electrical signal .Nature does this with a purpose .   It is essential for the ventricles to fill adequately . We call it as PR interval.

So, when the basic purpose of AV junction is slow down the conduction it is logical to expect it won’t get irritated that  easily  and  result in ectopic beats. So JPDs are less common than other forms of ectopic beats.

What is invisible JPD and HIS ectopics ?

We should realise many of the JPDs  & his bundle ectopics are not conducted ,  the impulses simply dissipate down hill .  Unlike the atrium and ventricle the junctional and his tissue has no associated chambers to depolarise , hence they are not  often visible in the surface ECG.The only evidence in the surface ECG may be an unexpected pause which represents concealed conduction. A EP  study  of the bundle  ECG often unmask these silent JPDs and His VPDs.

 JPDs are  less common  , while  junctional escape beats are the  hall mark of any  severe supraventrcualr bradycardia . How  does  that occur ?

AV junctional cells have  an unique behavior in that , it comes to the rescue of the heart whenever the native SA node becomes too slow  . This happens as a passive response .We call this as junctional escape beat.The major difference between a JPD and Junctional escape beat (JEP or JED )  is in the initial timing of the beat . Escape beat comes late .The coupling interval of escape beat (We generally use coupling interval for ectopic beats only , but  it helps to understand )  will be longer than the previous sinus cycle. So escape beat is never premature (Rather a  post mature beat !) .Ectopic beats are always premature ,( except Interpolated ) and occurs earlier than the next anticipated beat.

The other difference is escape beats are tolerated well as the primary purpose is to rescue back up.Their rate is generally equal to the  intrinsic rate  of AV junction ie around 40-50.

General characters  of  Junctional  premature beats and tachycardia

  • Fortunately rare,  fires at a  higher rate.(Unlike junctional escape beats )
  • Enhanced automaticity is a common mechanism
  • Reentrant JPD is rare , unless the patient has AVNRT or it’s variant  physiology.
  • Manifest as narrow qrs complex . JPD with aberrancy is distinctly possible .In that case differentiation from VPD may be difficult.Retograde  P wave morphology may help.But it is non specific as VPDs also have varied atrial capture depending upon the VA conduction .
  • Causes include Hypoxia,  (Rarely ischemic junctional tachycardia. ) common causes include  digoxin induced , post operative states, incessant JT
  • JTs are Difficult to control.Overdrive pacing may be needed. May lead onto tachycardic cardiomyopathy.
  • A benign form of junctional ectopic tachycardia is also reported .

Importance of Junctional escape rhythm

The role of AV junctional escape is vital in extreme bradycardia , as if the junction fails to escape the dangerous ventricular cells take  over  electrical control  and that’s  bad news for the heart  with  sinister consequence.The situation can rapidly degenerate to VT  , what we call  as phase  dependent or brady dependent VT. The treatment for which is increasing the proximal heart rate. By isoprenaline or pacing. So the AV junction does  a delicate balancing act .At times of tachycardia it blocks unnecessary impulses.At times of extreme  bradycardia it assists the heart as escape rhythm . The problem here is many of the disorders that affect SA node , affect the AV node as well .So ,  AV node may not be able to help the SA node always.That is the reason many extreme myocardial end up with VT straightaway.

Final message

JPDs are not very uncommon as one would believe.It has some unique properties. There are vital difference between JPDs and junctional escape beats.JPDs can trnasform into JTs in local pathological milleu and as a rule they are difficult to control.

AVNRT is also a type of  junctional  tachycardia  but,  it  is delinked from  the ( unofficial  ! ) classification of JT  , not  with  any  academic purpose  but by tradition.

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                              Cardioversion with DC shock  offers immediate cure in many of the dangerous ventricular and atrial tachycardias.  It is often  taught ,  any hemodynamically unstable tachycardia  refractory to  medical therapy respond to electrical cardioversion.  One should also  remember electricity is in fact be called  as a drug !  and it should be delivered in proper form and dose. Here it is the paddle size, paddle position and the axis of current flow all are important. Now we have bi phasic currents for better efficacy.

                             While it is true, most of cardiac arrhythmias respond to shock,  there are few which do not respond or respond very transiently.There are few arrhythmias  in which ,DC shock is not only ineffective but may precipitate a ventricular  fibrillation.

                            Generally arrhythmias of reentrant etiology respond well to DC shock were interuption of  electrical circuit by external current is easily possible. In arrhythmia’s of enhanced automaticity ,  and ectopic tachycardia  it is difficult  to extinguish  the tachycardia focus with DC shock .

Arrhythmias where DC shock is not going to work are

A. Mutifocal atrial tachycardia(MAT)

B. Digoxin induced arrhythmias.Patients who are on digoxin,  has  enhanced ventricular  automaticity.These patients if they  get a DC shock will unmask the  ectopic foci.

C. In elderly with atrial fibrillation and sinus node dysfunction it may be dangerous to shock them with out temporary pacing support as sinus node goes for prolonged sleep mode.

D.In electrical storm with VT ,  if more than three shocks are required within a minute,  the VT will most often going to be permanent and the  electrical therapy can be termed as a failure. These patients will require intensive pharmacological management( Including magnesium, bretyllium etc)

E. And finally , sinus tachycardia (whatever the rate)  is an absolute contraindication for DC shock.

 Verapmil is often effective in MAT  but correction of hypoxia and acidosis may be critical.For digoxin induced arrhythmias phenytoin may be tried.

What to do when the DC shock fails?

  • It will be a  tricky situation and one wonder what to do next when the so called  universal antidote for cardiac arrhythmia fails !
  • Cellular internal millieu  is altered  by hypoxia and acidosis .It may prevent the  effectiveness of cardioversion.So try to correct them .
  • Over dirve atrial  pacing  is one option for automatic tachycardia.
  • And now ablation of arrhythmic focus is possible with radio frequency waves  in some of these patients.( Diffiuclt as an emergency procedure)

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