Regularized Atrial Fibrillation

      Digoxin remains commonly used in clinical practice for atrial fibrillation patients with or without heart failure, despite its narrow therapeutic index and the availability of advanced pharmacologic therapies in the management of these patients. Digoxin toxicity is often overlooked and misdiagnosed, as the clinical manifestations of digoxin intoxication are often nonspecific, and serum digoxin levels do not always correlate with toxicity. An 89-year-old woman presented to the emergency room with a 1-week history of poor oral intake, fatigue, confusion, weakness, and dizziness. Her significant medical history included a bioprosthetic aortic valve replacement, permanent atrial fibrillation, hypertension, and stage 3 chronic kidney disease. She was on aspirin, warfarin, amlodipine, and furosemide on a daily basis. She had also been taking 125 µg of digoxin daily for the past 12 years. On presentation, she was afebrile with a regular heart rate of 40 beats per minute; her blood pressure was 128/58 mmHg, and her oxygen saturation was 95% on room air. A 12-lead electrocardiogram (ECG) obtained on admission is shown in Figure 1.
      Fig 1
      Figure 1Admission ECG showing atrial fibrillation, prolonged QRS complexes with right intraventricular conduction delay, and regular RR intervals suggesting an escape rhythm.
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