Tag Archives: sudden death

Has The Digoxin Death Knell Sounded: Farewell To Foxglove?

The lovely but deadly foxglove plant encountered randomly on a hike through glorious Wales on a dreary, rainy day.

The skeptical cardiologist is fascinated by the cardiac drug digoxin and the plant from which it is derived, the foxglove.

I wrote about “foxglove equipoise” in a previous post, touching on the contributions of William Withering in the 1700s, to understanding the toxicity and therapeutic benefits of the foxglove, and more recent concerns that digoxin increases mortality in patients with heart failure.

At the American College of Cardiology Scientific Sessions in Washington, D.C. yesterday, a paper showing higher mortality for patients on digoxin may be the final nail in the foxglove coffin.

Despite lack of evidence for its safety in the treatment of atrial fibrillation from randomized trials, digoxin is used in 30% of patients with atrial fibrillation (AF) worldwide, and current AF guidelines recommend it for rate control in patients with AF (with and without heart failure).

The investigators used data from the ARISTOTLE study of apixiban versus warfarin for their analysis.

They looked at mortality in patients taking or not taking digoxin at baseline, using a Cox model with propensity weighting, which included demographic features as well as biomarkers and digoxin levels at baseline. Major findings:

-In patients already taking digoxin, mortality was not higher in digoxin users, however, the risk of death was related to dig levels: for every 0.5 ng/ml increase in dig level, the risk of death rose by 19 percent and if dig level was >1.2 ng/ml the death rate increased by 56 percent. 

Patients not taking digoxin before the trial who began taking it over the course of the study had a 78 percent increase in the risk of death from any cause and a four-fold increased risk of sudden death after starting digoxin use.  Most sudden deaths occurred within six months after digoxin was started.

Risk of death with initiation of digoxin was increased in patients with and without heart failure.

The use of foxglove to treat dropsy is a fascinating and instructive chapter in the history of medicine.

This study added to prior systematic reviews suggests that it is time to end the use of digitalis and close the chapter.

William Withering might turn over in his grave but at least we won’t be sending afib patients to join him prematurely!

Dropsily Yours,

-ACP

 

Two Three Letter Words For Saving Lives: CPR and AED

Every two years the skeptical cardiologist has to get recertified in Basic Life Support for medical personnel. This involves a review of what, the American Heart Association has decided, are important changes in guidelines for Emergency Cardiac Care and cardiopulmonary resuscitation (CPR).

I highly recommend all of you undergo such training. Although the survival rate of patients with “out of hospital cardiac arrests” is very low, your appropriate actions could be crucial in saving the life of a stranger or a loved one.

About a year ago one of my patients suddenly, and without any warning symptoms, collapsed at work. Fortunately for him, a co-worker had undergone CPR training and initiated chest compressions right away. When paramedics arrived 15 minutes later he was defibrillated from ventricular fibrillation and taken to a nearby hospital.

Our best information on cardiac arrest suggests that without CPR, irreversible brain damage (due to lack of oxygen) develops in about four minutes after the heart stops beating. Even with good CPR, the longer the time interval from arrest to defibrillation, the less likely the patient is to survive with good brain function.

Thus, the two keys to helping someone who drops dead next to you are beginning effective CPR (and compression only is OK) and defibrillating a fibrillating heart as soon as possible.

My patient was comatose on arrival to the hospital and was put into a hypothermic state, a process which has been shown to improve neurological outcome in cardiac arrest victims. Doctors informed his wife that they thought his prognosis was bad-less than 5% chance of surviving with intact brain function.  After three days he awoke from his coma and was transferred to my hospital.

I visited him in the ICU and other than a sore chest and an inability to remember the events surrounding his cardiac arrest, he was mentally normal and felt great. He continues to do very well to this day, but without the bystander CPR that he received (followed by the defibrillation) he would be one of the 350,000 who die of cardiac arrest in the US each year.

If the co-worker had not initiated CPR for the many minutes it took for EMRs to arrive, my patient’s brain would have been dying from lack of oxygen and it is most likely he would have suffered severe encephalopathy or brain death.

Recognizing Cardiac Arrest

Recognizing when someone needs CPR is a critical first step in the chain of events that can improve survival in cardiac arrest.

You are looking for two things before starting CPR:

  1. Unresponsiveness. The victim  does not move and does not respond at all to either verbal or physical stimulation.
  2. Breathing is absent or atonal (meaning ineffective , intermittent gasps).

Agonal respirations have also been described as “snoring, snorting, gurgling, or moaning or as barely, labored, noisy, or heavy breathing.”  Studies have shown that agonal respirations are common in the early minutes after cardiac arrest and are associated with good outcomes.

Two Steps To Save A Life

The two key components of resuscitation are CPR and defibrillation.

Performing these steps is simple and straightforward.

The earlier they are started, the more likely the victim is to survive.

If someone collapses near you and they are unresponsive and not breathing, they need CPR and an AED. Call for help as you are starting CPR.

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Cardiopulmonary Resuscitation (CPR)

CPR consists of repeated compressions of a victim’s chest.

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I came across this machine recently. You can learn and practice hands-only CPR using it.

Everyone has seen dramatizations of CPR and it is quite simple to do even without training. Basically, you want to “push hard and fast in the center of the chest.”

CPR training undergoes some tweaking over time as more scientific data is obtained but the fundamentals remain the same. The changes that the AHA is emphasizing in their current CPR courses are:

-depress the chest at least 2 inches

-depress the chest 100-120 times per minuCPR-Certificationte (as opposed to just >100 time per minute).

Of note, the recommended sequence has changed from A, B, C, to C, A, B. Compressions right away followed by assessment of airway and then mouth-to-mouth breathing.  In fact, because compressions without breaths have been shown to be as effective as with breaths, if you are uncomfortable giving breaths, recommendations now are to just do CPR.

 

Initiating CPR and calling 911 are the greatest initial things you can do for the person who collapses next to you.

However, the earlier you can defibrillate that person from ventricular fibrillation, the better their chance of survival.

Ambulatory electronic defibrillators or AEDS , if available, are very easy to use devices that can shorten the time to defibrillation and are the second key to successful resuscitation of cardiac arrest victims in the community.

I’ll talk about using them in a subsequent post.

antimortatorially yours

-ACP