Recognition of Digitalis Intoxication in the Presence of Atrial Fibrillation

Diagnosis and Treatment1 November 1967Recognition of Digitalis Intoxication in the Presence of Atrial FibrillationJOHN A. KASTOR, M.D., PETER M. YURCHAK, M.D., F.A.C.P.JOHN A. KASTOR, M.D., PETER M. YURCHAK, M.D., F.A.C.P.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-67-5-1045 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThere is no agent in the pharmacopeia so useful, yet so potentially hazardous, as digitalis. Lifesaving to thousands with heart failure, it has been life-ending to countless others in whom signs of toxicity went unrecognized.PREDISPOSING FACTORSPhysicians have become increasingly aware in recent years of the symptoms and electrocardiographic signs of digitalis intoxication. This is due in part to detailed descriptions of certain characteristic digitalis-induced arrhythmias (1). Furthermore, there is growing recognition that the toxic dose is often not far removed from the therapeutic (2-4) and that certain patients are predisposed to the development of toxic manifestations. Some of...References1. LOWNWYATTLEVINE BNFHD: Paroxysmal atrial tachycardia with block. Circulation 21: 129, 1960. CrossrefMedlineGoogle Scholar2. HERRMANN GR: Digitoxicity in the aged; recognition, frequency, and management. Geriatrics 21: 109, 1966. MedlineGoogle Scholar3. ROSENBERGGRAETTINGER MSJS: Digitalis intoxication—management and prevention. DM, p. 1, November 1962. Google Scholar4. SOFFER A: Iatrogenic aspects of digitalis intoxication. JAMA 192: 987, 1965. CrossrefMedlineGoogle Scholar5. BELLET S: Atrial fibrillation in the elderly patient. Geriatrics 21: 239, 1966. MedlineGoogle Scholar6. CASTELLANOSLEMBERG AL: The relationship between digitalis and A-V nodal tachycardia with block. Amer. Heart J. 66: 605, 1963. CrossrefMedlineGoogle Scholar7. CROUCHHERRMANNHEJTMANCIK RBGRMR: Digitalis intoxication. Texas J. Med. 52: 714, 1956. MedlineGoogle Scholar8. DALL JL: Digitalis intoxication in elderly patients. Lancet 1: 194, 1965. CrossrefMedlineGoogle Scholar9. DALL JL: Digitalis intoxication. Amer. Heart J. 70: 572, 1965. CrossrefMedlineGoogle Scholar10. DELMANSTEIN AJE: Atrial flutter secondary to digitalis toxicity; report of 3 cases and review of the literature. Circulation 29: 593, 1964. CrossrefGoogle Scholar11. DUBNOWBURCHELL MHHB: A comparison of digitalis intoxication in two separate periods. Ann. Intern. Med. 62: 956, 1965. LinkGoogle Scholar12. FEIBUSH J: Unusual sensitivity to digitalis. Amer. J. Cardiol. 3: 121, 1959. CrossrefMedlineGoogle Scholar13. SCHOTT A: Observations on digitalis intoxication—a plea. Postgrad. Med. J. 40: 628, 1964. CrossrefMedlineGoogle Scholar14. SHRAGER MW: Digitalis intoxication. Arch. Intern. Med. (Chicago) 100: 881, 1957. CrossrefGoogle Scholar15. SOFFER A: The changing clinical picture of digitalis intoxication. Arch. Intern. Med. (Chicago) 107: 681, 1961. CrossrefGoogle Scholar16. SOFFER A: The importance of atrio-ventricular dissociation in the diagnosis of digitalis intoxication. Dis. Chest 41: 422, 1962. CrossrefMedlineGoogle Scholar17. DREIFUSBARTOLUCCILIKOFF LSGW: Nodal tachycardia: etiology and therapy (abstract). Circulation 22: 741, 1960. Google Scholar18. DREIFUSLIKOFF LSW: Serious cardiac arrhythmias following acute myocardial infarction (abstract). Circulation 24: 922, 1961. Google Scholar19. DREIFUSKATZWATANABELIKOFF LSMYW: Clinical significance of disorders of impulse formation and conduction in the atrioventricular junction. Amer. J. Cardiol. 11: 384, 1963. CrossrefGoogle Scholar20. RODENSKYWASSERMAN PLF: Observations on digitalis intoxication. Arch. Intern. Med. (Chicago) 108: 171, 1961. CrossrefMedlineGoogle Scholar21. SODEMAN WA: Diagnosis and treatment of digitalis toxicity. New Eng. J. Med. 273: 35, 93, 1965. CrossrefMedlineGoogle Scholar22. BAUMDICKBLUMKAUPECARBALLO GLMMAAJ: Factors involved in digitalis sensitivity in chronic pulmonary insufficiency. Amer. Heart J. 57: 460, 1959. CrossrefMedlineGoogle Scholar23. FRIEDBERG CK: Diseases of the Heart, 3rd ed. 1787 pp. W. B. Saunders Co., Philadelphia, 1966. Google Scholar24. TENCH WR: The triad of tachycardia, digitalis toxicity and mercurial-fast edema in congestive heart failure complicated by pulmonary embolism. Amer. J. Med. 19: 869, 1955. CrossrefMedlineGoogle Scholar25. RABBINODREIFUSLIKOFF MDLSW: Cardiac arrhythmias following intracardiac surgery. Amer. J. Cardiol. 7: 681, 1961. CrossrefMedlineGoogle Scholar26. DOHERTYPERKINSWILSON JEWHMC: Studies with tritiated digoxin in renal failure. Amer. J. Med. 37: 536, 1964. CrossrefMedlineGoogle Scholar27. DOHERTYPERKINS JEWH: Digoxin metabolism in hypo- and hyperthyroidism. Studies with tritiated digoxin in thyroid disease. Ann. Intern. Med. 64: 489, 1966. LinkGoogle Scholar28. LUBASHCOHENBRAVEMANRUBINLUCKEY GDBDWSALEH: Electrocardiographic changes during hemodialysis with artificial kidney. II. The treatment of digitalis intoxication. Circulation 19: 552, 1959. CrossrefMedlineGoogle Scholar29. CORAZZAPASTOR LJBH: Cardiac arrhythmias in chronic cor pulmonale. New Eng. J. Med. 259: 862, 1958. CrossrefGoogle Scholar30. MCINTOSHMORRIS HDJJ: Problems in the use of digitalis in the management of congestive heart failure. Progr. Cardiov. Dis. 7: 360, 1965. CrossrefMedlineGoogle Scholar31. GOLDBERGER E: The changing clinical picture of digitalis intoxication. Amer. J. Cardiol. 9: 639, 1962. CrossrefGoogle Scholar32. ROBERTSONHOLLENHORSTCALLAHAN DMRWJA: Ocular manifestations of digitalis toxicity: discussion and report of three cases of central scotomas. Arch. Ophthal. (Chicago) 76: 640, 1966. CrossrefMedlineGoogle Scholar33. WHITE PD: An important toxic effect of digitalis overdosage on the vision. New Eng. J. Med. 272: 904, 1965. CrossrefMedlineGoogle Scholar34. CHURCHMARRIOTT GHJ: Digitalis delirium: a report on three cases. Circulation 20: 549, 1959. CrossrefMedlineGoogle Scholar35. LEWINN EB: Gynecomastia during digitalis therapy: report of eight additional cases with liver-function studies. New Eng. J. Med. 248: 316, 1953. CrossrefMedlineGoogle Scholar36. VON CAPELLERCOPELANDSTERN DGDTN: Digitalis intoxication: a clinical report of 148 cases. Ann. Intern. Med. 50: 869, 1959. LinkGoogle Scholar37. FRIEDBERGDONOSO CKE: Arrhythmias and conduction disturbances due to digitalis. Progr. Cardiov. Dis. 2: 408, 1960. CrossrefMedlineGoogle Scholar38. BACANER M: The occurrence of a rapid ventricular rate during atrial fibrillation as a paradoxical manifestation of digitalis intoxication. Amer. Heart J. 56: 685, 1958. CrossrefMedlineGoogle Scholar39. FISCHGREENSPANKNOEBELFEIGENBAUM CKSBH: Effect of digitalis on conduction of the heart. Progr. Cardiov. Dis. 6: 343, 1964. CrossrefMedlineGoogle Scholar40. PICK A: Digitalis and the electrocardiogram. Circulation 15: 603, 1957. CrossrefMedlineGoogle Scholar41. PICK A: Personal communication to the authors, 1966. Google Scholar42. SCHOENFELDMESSELOFFFARIANPARDO MRCRKU: Atrial fibrillation with rapid ventricular rate due to digitalis. New York J. Med. 62: 1474, 1962. MedlineGoogle Scholar43. ARAVANISMICHAELIDES CG: Paroxysmal auricular flutter and right bundle branch block following digitalis therapy. Amer. J. Cardiol. 4: 124, 1959. CrossrefMedlineGoogle Scholar44. CHUNGTHOMAS KYJ: Arrhythmias caused by digitalis toxicity. Geriatrics 20: 1006, 1965. MedlineGoogle Scholar45. COFFMANWHIPPLE JDGH: Atrial flutter as a manifestation of digitalis toxicity. Circulation 19: 188, 1959. CrossrefMedlineGoogle Scholar46. HOFFMANCRANEFIELD BFPF: The physiological basis of cardiac arrhythmias. Amer. J. Med. 37: 670, 1964. CrossrefMedlineGoogle Scholar47. DREIFUSMCGARRYKIMBIRIS LSTFD: New concepts in the approach to digitalis therapy for atrial fibrillation. Dis. Chest 44: 197, 1963. CrossrefMedlineGoogle Scholar48. BELLET S: Clinical Disorders of the Heart Beat, 2nd ed. Lea & Febiger, Philadelphia, 1963, pp. 395-400. Google Scholar49. PICKDOMINGUEZ AP: Non-paroxysmal A-V nodal tachycardia. Circulation 16: 1022, 1957. CrossrefMedlineGoogle Scholar50. LANGENDORFPICK RA: Cardiac arrhythmias in infants and children, in Heart Disease in Children. Diagnosis and Treatment, edited by GASUL, B. M., ARCILLA, R. A., LEV, M. J. B. Lippincott Co., Philadelphia, 1966, pp. 121-167. Google Scholar51. HWANGLANGENDORF WR: Auriculoventricular nodal escape in the presence of auricular fibrillation. Circulation 1: 930, 1950. CrossrefGoogle Scholar52. GOODMANPICK RMA: An unusual type of intermittent A-V dissociation in acute rheumatic myocarditis. Amer. Heart J. 61: 259, 1961. CrossrefMedlineGoogle Scholar53. KISTIN AD: Problems in the differentiation of ventricular arrhythmia from supraventricular arrhythmia with abnormal QRS. Progr. Cardiov. Dis. 9: 1, 1966. CrossrefGoogle Scholar54. MARRIOTTSANDLER HJIA: Criteria, old and new, for differentiating between ectopic ventricular beats and aberrant ventricular conduction in the presence of atrial fibrillation. Ibid., p. 18. Google Scholar55. PICK A: Aberrant ventricular conduction of escaped beats. Preferential and accessory pathways in the A-V junction. Circulation 13: 702, 1956. CrossrefMedlineGoogle Scholar56. WALSH TJ: Ventricular aberration of A-V nodal escape beats. Comments concerning the mechanism of aberration. Amer. J. Cardiol. 10: 217, 1962. CrossrefMedlineGoogle Scholar57. MARRIOTTMENDENDEZ HJMM: A-V dissociation revisited. Progr. Cardiov. Dis. 8: 522, 1966. CrossrefMedlineGoogle Scholar58. PICK A: A-V dissociation. A proposal for a comprehensive classification and consistent terminology. Amer. Heart J. 66: 147, 1963. CrossrefMedlineGoogle Scholar59. BRAUNWALDKLOCKE EFJ: Digitalis. Ann. Rev. Med. 16: 371, 1965. CrossrefMedlineGoogle Scholar60. DREIFUSMCKNIGHTKATZLIKOFF LSEHMW: Digitalis intolerance. Geriatrics 18: 494, 1963. Google Scholar61. IRONSORGAIN GVES: Digitalis-induced arrhythmias and their management. Progr. Cardiov. Dis. 8: 539, 1966. CrossrefMedlineGoogle Scholar62. GOLDBERGBRISTOWPARKERRITZMANN LMJDBMLW: Paroxysmal atrial tachycardia with atrioventricular block: its frequent association with chronic pulmonary disease. Circulation 21: 499, 1960. CrossrefGoogle Scholar63. BELLET S: Atrial fibrillation. JAMA 189: 419, 1964. CrossrefMedlineGoogle Scholar64. THEILENWARKENTINJANUARY EODLLE: The use of digitalis in arrhythmias. Progr. Cardiov. Dis. 7: 261, 1964. CrossrefMedlineGoogle Scholar65. SCHERFCOHEN DJ: The Atrioventricular Node and Selected Cardiac Arrhythmias. 466 pp. Grune & Stratton, Inc., New York, 1964. Google Scholar66. LANGENDORFPICK RA: Approach to the interpretation of complex arrhythmias. Progr. Cardiov. Dis. 2: 706, 1960. CrossrefMedlineGoogle Scholar67. PICKLANGENDORFKATZ ARLN: A-V nodal tachycardia with block. Circulation 24: 12, 1961. CrossrefMedlineGoogle Scholar68. DREIFUSRABBINOWATANABE LSMDY: Newer agents in the treatment of cardiac arrhythmias. Med. Clin. N. Amer. 48: 371, 1964. CrossrefMedlineGoogle Scholar69. DREIFUSRABBINOWATANABE LSMDY: New antiarrhythmic drugs: clinical evaluation, in Cardiovascular Drug Therapy, edited by BREST, A. N., MOYER, J. H. Grune & Stratton, Inc., New York, 1965, pp. 491-504. Google Scholar70. DONOSOADLERFRIEDBERG ELNCK: Unusual forms of second-degree atrioventricular block, including Mobitz Type-II block, associated with the Morgagni-Adams-Stokes syndrome. Amer. Heart J. 67: 150, 1964. CrossrefMedlineGoogle Scholar71. KAUFMANWACHTELROTHFIELDBERNSTEIN JGFWEA: The association of complete heart block and Adams-Stokes syndrome in two cases of Mobitz type of block; case reports. Circulation 23: 253, 1961. CrossrefMedlineGoogle Scholar72. HELLMANLIND EA: Bidirectional tachycardia. Amer. Heart J. 51: 140, 1956. CrossrefMedlineGoogle Scholar73. RUNCORYANBOOTH VJMRW: Bidirectional tachycardia. Three cases and a review of its mechanism. Amer. J. Cardiol. 9: 626, 1962. CrossrefMedlineGoogle Scholar74. KNOEBELMCHENRY SBPL: Atrial fibrillation and digitalis: a complex problem. J. Indiana Med. Ass. 59: 135, 1966. Google Scholar75. WITHERING W: An account of the Foxglove and some of its medical uses; with practical remarks on dropsy, and other diseases, in Classics of Cardiology, vol. 1, edited by WILLIUS, F. A., KEYS, T. E. Dover Publications, Inc., New York, 1961, p. 245. Google Scholar76. DREIFUSLIKOFFBENDER LSWSR: Serious cardiac arrhythmias induced by digitalis. Prognosis and management (abstract). Circulation 24: 922, 1961. Google Scholar77. CONN RD: Diphenylhydantoin sodium in cardiac arrhythmias. New Eng. J. Med. 272: 277, 1965. CrossrefMedlineGoogle Scholar78. HARRIS A: Long-term treatment of paroxysmal cardiac arrhythmias with propranolol. Amer. J. Cardiol. 18: 431, 1966. CrossrefMedlineGoogle Scholar79. LURIAADELSONMILLER MHEIAJ: Acute and chronic effects of an adrenergic beta-receptor blocking agent (propranolol) in treatment of cardiac arrhythmias. Circulation 34: 767, 1966. CrossrefMedlineGoogle Scholar80. TURNER JR: Propranolol in the treatment of digitalis-induced and digitalis-resistant tachycardias. Amer. J. Cardiol. 18: 450, 1966. CrossrefMedlineGoogle Scholar81. WOLFSONROBBINSKRASNOW SSIN: Treatment of cardiac arrhythmias with beta-adrenergic blocking agents. Clinical and experimental studies. Amer. Heart J. 72: 177, 1966. CrossrefGoogle Scholar82. ROSENLISAKRUBIN MRRIL: Diphenylhydantoin in cardiac arrhythmias (abstract). Circulation 23-24 (suppl. III): 201, 1966. Google Scholar83. SCHAMROTH L: Immediate effects of intravenous propranolol on various cardiac arrhythmias. Amer. J. Cardiol. 18: 438, 1966. CrossrefMedlineGoogle Scholar84. CORWINKLEINFRIEDBERG NDMJCK: Countershock conversion of digitalis-associated paroxysmal atrial tachycardia with block. Amer. Heart J. 66: 804, 1963. CrossrefMedlineGoogle Scholar85. FISCHSHIELDSRIDOLFOFEIGENBAUM CJPSAH: Effect of potassium on conduction and ectopic rhythms in atrial fibrillation treated with digitalis. Circulation 18: 98, 1958. CrossrefMedlineGoogle Scholar86. FISCHSTEINMETZFEIGENBAUM CEFH: Interrelationship of digitalis and potassium. J. Indiana Med. Ass. 56: 190, 1963. Google Scholar87. SOMLYO AP: The toxicology of digitalis. Amer. J. Cardiol. 5: 523, 1960. CrossrefMedlineGoogle Scholar88. SURAWICZMAZZOLENI BA: Role of potassium in ventricular asystole, in Sudden Cardiac Death, edited by SURAWICZ, B., PELLEGRINO, E. D. Grune & Stratton, Inc., New York, 1964, pp. 90-96. Google Scholar89. ZIMMERMANGENTSCHGALE HBKWAH: The action of potassium on the atrioventricular node in digitalized patients. Dis. Chest 43: 377, 1963. CrossrefMedlineGoogle Scholar90. CASTELLANOSLEMBERGSCHEIBBUDKIN ALRJA: Cardioversion of A-V nodal tachycardias. Amer. J. Cardiol. 18: 884, 1966. CrossrefMedlineGoogle Scholar91. GILBERTCUDDY RRP: Digitalis intoxication following conversion to sinus rhythm. Circulation 32: 58, 1965. CrossrefMedlineGoogle Scholar92. KASTORDESANCTIS JARW: The electrical conversion of atrial fibrillation. Amer. J. Med. Sci. 253: 511, 1967. CrossrefMedlineGoogle Scholar93. KLEIGERLOWN RB: Cardioversion and digitalis. II. Clinical studies. Circulation 33: 878, 1966. CrossrefMedlineGoogle Scholar94. Direct-current shock for atrial fibrillation (leading article). Lancet 2: 689, 1966. MedlineGoogle Scholar95. LOWNKLEIGERWILLIAMS BRJ: Cardioversion and digitalis drugs: charged threshold to electric shock in digitalized animals. Circ. Res. 17: 519, 1965. CrossrefMedlineGoogle Scholar96. PAULKHURST EAJW: Clinical problems of cardioversion. Amer. Heart J. 70: 248, 1965. CrossrefMedlineGoogle Scholar97. RABBINOLIKOFFDREIFUS MDWLS: Complications and limitations of direct-current countershock. JAMA 190: 417, 1964. CrossrefMedlineGoogle Scholar98. MORRISPETERMCINTOSH JJRHHD: Electrical conversion of atrial fibrillation. Immediate and long-term results and selection of patients. Ann. Intern. Med. 65: 216, 1966. LinkGoogle Scholar99. ROBINSONWAGNER HJJA: D. C. cardioversion causing ventricular fibrillation. Amer. J. Med. Sci. 249: 300, 1965. CrossrefMedlineGoogle Scholar100. LEON-SOTOMAYORMYERSHYATTHYMAN LWSKHAL: Digitalis-induced ventricular asystole treated by an intracardiac pacemaker. Amer. J. Cardiol. 10: 298, 1962. CrossrefMedlineGoogle Scholar101. KATZPICK LNA: Clinical Electrocardiography. I. The Arrhythmias. Lea & Febiger, Philadelphia, 1956, p. 531. Google Scholar102. MARRIOTT HJ: Armchair arrhythmias, in Tampa Tracings. Oldsmar, Florida, 1965, p. 114. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAuthors: JOHN A. KASTOR, M.D.; PETER M. YURCHAK, M.D., F.A.C.P.Affiliations: Boston, MassachusettsFrom the Departments of Medicine, Harvard Medical School and The Massachusetts General Hospital (Cardiac Unit), Boston, Mass.This study was supported in part by training grant HE-5196, U. S. Public Health Service, Washington, D. C.At the time of this study Dr. Kastor was a Teaching Fellow in Medicine, Harvard Medical School, and a Clinical and Research Fellow in Medicine, The Massachusetts General Hospital.Requests for reprints should be addressed to John A. Kastor, M.D., Cardiac Unit, The Massachusetts General Hospital, Boston, Mass. 02114. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byCurrent pharmacotherapeutic strategies for cardiac arrhythmias in heart failureDigoxin Use to Control Ventricular Rate in Patients with Atrial Fibrillation and Heart Failure Is Not Associated with Increased MortalityDigoxin toxicity in renal failure: role of the electrocardiogramComputed tomography visualization of intracerebral haematoma 'pouring' directly into ventricular systemArrhythmia DiagnosisDigitalisProarrhythmia in Patients Treated for Atrial Fibrillation or FlutterRodney H. Falk, MDThe Management of Atrial FibrillationAtrial Fibrillation: New Findings About an Old NemesisDigitalis: where are we now?Antiarrhythmic treatment: An overviewDiagnosis and Management of Cardiac Arrhythmias in the Postoperative PeriodGlykosideRecognition of digitalis intoxication in the presence of atrial fibrillation: Analysis of 167 casesThe Role of Holter Monitoring in Detecting Digitalis-Provoked ArrhythmiasA new method for quantifying ventricular regularization during atrial fibrillationThe Treatment of Common Cardiac ArrhythmiasTissue Sensitivity to Drugs in Disease StatesConcealed Sinus RhythmAppearance of Atrial Rhythm with Absent P Wave in Longstanding Atrial FibrillationInfluence of exercise on arrhythmias induced by digitalis-diuretic therapy in patients with atrial fibrillationAtrial Arrhythmias with Low Amplitude P WavesDigitalis Intoxication in Patients with Atrial FibrillationDouble Atrial and Atrioventricular Junctional TachycardiaIntracardiac Electrocardiography in the Analysis and Understanding of Cardiac ArrhythmiasBRUCE N. GOLDREYER, M.D.Localization of Ventricular Irritability by Epicardial MappingDigitalis IntoxicationDIGOXIN DOSAGE AND VENTRICULAR RATE AT REST AND EXERCISE IN PATIENTS WITH ATRIAL FIBRILLATIONRecognition and therapy of digitalis toxicityRecognition and therapy of digitalis toxicityCardiac Arrhythmias in the Postoperative PatientQuantitative Methods for the Recognition of Atrioventricular Junctional Rhythms in Atrial FibrillationAtrial fibrillation and digitalis toxicity 1 November 1967Volume 67, Issue 5 Page: 1045-1054 Keywords Arrhythmia Atrial fibrillation Electrocardiography Heart failure Hospital medicine Intoxication Medical services Signs and symptoms Toxicity ePublished: 1 December 2008 Issue Published: 1 November 1967 PDF downloadLoading ...