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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.
Figure 1Admission ECG showing atrial fibrillation, prolonged QRS complexes with right intraventricular
conduction delay, and regular RR intervals suggesting an escape rhythm.
Digoxin use in patients with atrial fibrillation and adverse cardiovascular outcomes: a retrospective analysis of the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF).
2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
