Digoxin intoxication: An old enemy in modern era.

OBJECTIVES: Although development of new treatment modalities limited digoxin usage, digoxin intoxication is still an important issue which could be easily overlooked. In this report, we analyzed a case series definitively diagnosed as digoxin intoxication in the modern era. METHODS: We analyzed 71 patients hospitalized with digoxin intoxication confirmed by history, complaints, clinical and electrocardiograph (ECG) findings, and serum digoxin levels > 2.0 ng/mL, during a five year period. The demographic and clinical data, indications for digoxin use, digoxin dosage, concurrent medications, laboratory data, hospital monitoring, and ECG findings were obtained from all patients. RESULTS: Thirty-eight of 71 patients (53.5%) had symptoms of heart failure during admission or later. Sixty-four percent of patients were older than 75 years. The percentage of females was 67%. Atrial fibrillation, hypertension and gastrointestinal complaints were more frequent in the females (64% in females, 30% in males, P = 0.007; 81% in female, 52% in males, P = 0.01; 50% in female, 17.3% in males, P = 0.008, respectively). The mortality rate during the hospital course was 7%. CONCLUSIONS: This report demonstrated the reduced mortality rates in patients with digoxin intoxication over the study period. Gastrointestinal complaints are the most common symptoms in this population.

Levosimendan versus dobutamine in heart failure patients treated chronically with carvedilol.

INTRODUCTION: Although beta-blockers are highly effective in the treatment of heart failure (HF), many patients with HF receiving a beta-blocker continue to become decompensated and require hospitalization for worsening HF. Levosimendan and dobutamine are used to manage decompensated HF, but their comparative effects on left ventricular (LV) function in patients prescribed beta-blockers are unknown. AIMS: The aim of this study was to compare the effects of dobutamine and levosimendan on LV systolic and diastolic functions in chronic HF patients treated chronically with carvedilol. Forty patients with chronic HF who had NYHA class III to IV symptoms, a LV ejection fraction (LVEF) <40%, and ongoing treatment with carvedilol were enrolled in this randomized (1:1), dobutamine controlled, open-label study. Before and 24 h after treatment, LVEF, mitral inflow peak E and A wave velocity, E/A ratio, the deceleration time of the E wave (DT), isovolumic relaxation time (IVRT), peak systolic (Sm) and early diastolic (Em) mitral annular velocity, and systolic pulmonary artery pressure (SPAP) were measured by echocardiography. RESULTS: Levosimendan produced a statistically significant increase in LVEF (28+/-5% vs. 33+/-3%), Sm (6.5+/-1.2 cm/s vs. 7.4+/-0.9 cm/s), DT (120+/-10 ms vs. 140+/-15 ms), and Em (7.5+/-0.4 cm/s vs. 8.1+/-0.5 cm/s) and significant decrease in E/A ratio (2.1+/-0.3 vs. 1.7+/-0.4) and SPAP (55+/-5 mmHg vs. 40+/-7 mmHg). No significant change occurred in LV systolic and diastolic function parameters, or SPAP with dobutamine treatment. Levosimendan did not significantly alter the heart rate (72+/-4 bpm vs. 70+/-3 bpm), systolic (105+/-5 mmHg vs. 102+/-4 mmHg), or diastolic blood pressure (85+/-5 mmHg vs. 83+/-5 mmHg) whereas with dobutamine treatment, all these parameters significantly increased. CONCLUSIONS: Dobutamine and levosimendan have different effects on LV functions in patients treated chronically with carvedilol. These differences should be considered when selecting inotropic therapy for decompensated HF receiving long-term carvedilol.

The role of tilt training in preventing recurrent syncope in patients with vasovagal syncope: a prospective and randomized study.

BACKGROUND: Recurrent vasovagal syncope (VVS) can be a severely disabling disorder that may lead to an important deterioration of quality of life because of the severity and recurrence of episodes. This study sought to investigate the effectiveness of repeated orthostatic self-training in preventing syncope in patients with recurrent VVS. METHODS: Eighty-two consecutive patients (mean age 41 +/- 4 years, 37 males) with recurrent VVS episodes and positive head-up tilt testing (HUT) were enrolled in this study. The patients were then randomized (1:1) to conventional therapy or conventional therapy plus additional tilt training sessions. The patients were followed for spontaneous syncope for one year. Primary end-points were the recurrence of syncope, the number of episodes, and the interval of time to the first recurrence. RESULTS: There were no significant differences of baseline clinical characteristics and parameters of HUT between the tilt training and control groups. The patients had 4 +/- 2/year syncopal episodes prior to the HUT. The mean follow-up after randomization was 12 +/- 2 months. Spontaneous syncope recurrence during follow-up was 56% (23 patients) versus 37% (15 patients) in the control and tilt training groups, respectively (P = 0.1). Time to first recurrence was also similar in both groups (70 +/- 20 days vs 50 +/- 15 days, P = 0.09). The frequency of recurrent syncopes was similar in all types of VVSs while the rate of episodes was significantly higher in control group in patients with vasodepressor type during follow-up period (32% vs 10%, P = 0.04). The mean number of recurrent syncope episodes was also similar in both groups (3 +/- 1 vs 2 +/- 1, P = 0.4). CONCLUSIONS: Tilt training was unable to influence the spontaneous syncope recurrence for recurrent VVS except for vasodepressor type.