Chest
Volume 114, Issue 3, September 1998, Pages 787-792
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The Short-term Effects of Digoxin in Patients With Right Ventricular Dysfunction From Pulmonary Hypertension

https://doi.org/10.1378/chest.114.3.787Get rights and content

Objective: Studies on the effects of digoxin in patients with right ventricular failure and normal left ventricular function have not been performed. We evaluated the short-term effects of digoxin administration in patients with primary pulmonary hypertension on hemodynamics, neurohormones, and baroreceptor responsiveness.

Design: This was a prospective study with patients serving as their own controls.

Setting: University Hospital Intensive Care Unit with central monitoring.

Patients: Seventeen patients with primary pulmonary hypertension and symptomatic heart failure were enrolled.

Interventions: Following baseline hemodynamics, neurohormonal samples were drawn and the heart rate response to change in blood pressure following a challenge of phenylephrine and nitroprusside were recorded. One mg of intravenous digoxin was given and the measurements repeated after 2 hours.

Results: Following digoxin there was a significant increase in cardiac output (3.49±1.2 to 3.81±1.2 L/min., p=0.028), a significant fall in norepinephrine (680±89 to 580±85 pg/ml, p=.013), and a significant increase in atrial natriuretic peptide (311±44 to 421±9 pg/ml, p=0.01). All of the patients had changes in heart rate and blood pressure following phenylephrine and nitroprusside challenge, but there was no significant difference in the change in heart rate response to change in blood pressure when rechallenged after digoxin treatment.

Conclusion: Digoxin produces a modest increase in cardiac output in patients with pulmonary hypertension and right ventricular failure, as well as a significant reduction in circulating norepinephrine. No detectable effects of digoxin on baroreceptor responsiveness were apparent. The use of digoxin in pulmonary hypertension is warranted.

(CHEST 1998; 114:787–792)

Abbreviations: ANP=atrial natriuretic peptide; EDTA=edetic acid; PPH=primary pulmonary hypertension

Section snippets

MATERIALS AND METHODS

Seventeen consecutive patients with PPH referred to our medical center for an initial evaluation were entered into the study. All patients were evaluated by clinical history, physical examination, ECG, chest radiography, perfusion lung scanning, pulmonary function testing, echocardiography, and right heart catheterization. Secondary causes of pulmonary hypertension were excluded on the basis of criteria established by the National Institutes of Health Registry on PPH.17 Normal left ventricular

Demographics

Seventeen patients were studied, 14 women and 3 men. Their ages were 42±12 years. The patients had severe PPH as manifest by an elevated mean pulmonary artery pressure (61 ± 19 mm Hg) and pulmonary vascular resistance (15±8 U).

Effects of Digoxin on Hemodynamics

The effects of digoxin on the hemodynamics in these patients are shown in Table 1. There was a significant increase in cardiac output of approximately 10% (3.49 to 3.81 L/min, p=0.028), which was manifest by an increased stroke volume, as heart rate remained essentially

DISCUSSION

Digitalis is a time-honored treatment of congestive heart failure. In the past, most studies on the effects of digitalis have focused on hemodynamics and increased myocardial contractility. Data demonstrating beneficial effects of digitalis on parameters such as cardiac output,2 left ventricular filling pressure,19, 20, 21, 22 and systemic vascular resistance23,24 have been obtained primarily in patients with abnormal baseline hemodynamics. It has also been proposed that the clinical

REACTIONS

In our experience, digitalis toxicity in patients with pulmonary hypertension and normal renal function is distinctly uncommon. Given its ease of administration, its low cost, and its potential to improve circulatory derangements in these patients, we believe that digoxin is a potentially useful medication for patients who present with right ventricular failure, either with isolated pulmonary hypertension or in combination with left ventricular systolic failure. The poor prognosis and high

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