Digoxin

Further improvement in symptoms may be accomplished with digoxin. Digoxin is considered the preferred agent among a number of available cardiac glycoside preparations. Digoxin neither improves nor worsens HF survival but does decrease symptoms, increase exercise capacity, and decrease the need for hospitalization in systolic dysfunction HF. Digoxin may be appropriate for patients who remain symptomatic on diuretics, ACE, and beta-blockers (see below). One clear indication for digoxin is for patients with HF, atrial fibrillation, and rapid ventricular response. Patients without an urgent indication for digoxin do not generally require loading doses. A daily oral dose of 0.125 mg to 0.25 mg will lead to steady state serum levels in 2 to 3 weeks. Elderly patients or those with renal insufficiency should receive a lower initial dose (0.125 mg every other day). Once a steady state is reached a serum digoxin level, electrocardiogram, BUN/creatinine, and serum electrolytes should be obtained. Results of the DIG trial suggest a serum concentration in the lower therapeutic range (0.7 to 1.2 ng/mL) retains the clinical benefit of digoxin while avoiding toxicity. Levels should be checked periodically and at the time of significant changes in HF symptoms or renal function.

Halting the Progression of HF and Delaying Mortality. ACE inhibitors and beta-blockers are two classes of medications that halt the progression of HF and reduce mortality. They do so by blunting the renin-angiotensin-aldosterone system and the sympathetic

nervous system, primary mechanisms in the pathophysiology of HF. Unless there are specific contraindications, the physician should prescribe ACE inhibitors to all patients with systolic dysfunction HF and strongly consider a trial of beta-blockers for

patients who are NYHA II and III with LV systolic dysfunction. ACE inhibitors have been shown to improve outcomes in in NYHA I and IV patients, but beta-blockers have not been well studied in these groups of HF patients.