Papadakis M A, Massie B M
Division of General Internal Medicine, San Francisco Veterans Administration Medical Center, California 94121.
Am J Med. 1988 Sep;85(3):365-8. doi: 10.1016/0002-9343(88)90588-8.
Digoxin is the third most commonly prescribed drug, yet limited information exists about its use in outpatients. Therefore, 242 medical outpatients receiving digoxin at our hospital were studied to evaluate the appropriateness of its use, defined by: (1) current or past supraventricular arrhythmias and/or (2) left ventricular systolic dysfunction (ejection fraction less than 45 percent).
Charts of 242 patients receiving digoxin were obtained. The patients were divided into groups based upon their physician's stated indication for digoxin therapy. Patients with only a clinical diagnosis of congestive heart failure (CHF) underwent echocardiography or radionuclide angiography to quantify left ventricular systolic function. Those with documented supraventricular arrhythmias and/or those with confirmed left ventricular systolic dysfunction were classified as appropriate candidates for digoxin.
Ninety-five percent of patients received digoxin for appropriate indications; 75 percent had confirmed supraventricular arrhythmias (27 percent also had CHF) and 20 percent with normal sinus rhythm had documented systolic dysfunction. However, physicians had difficulty in the clinical assessment of left ventricular function; 18 percent of patients with sinus rhythm and CHF by the Framingham scoring system and 20 percent of those with supraventricular arrhythmias and CHF had preserved systolic function. An S3 was present in 15 percent of patients with preserved ejection fraction and CHF and in 69 percent with low ejection fraction; hypertension was significantly more common in the former group. Noninvasive assessment of systolic function was obtained in 97 percent of patients independent of this study, yet some patients without supraventricular arrhythmias and with documented preservation of systolic function continued to receive the drug.
Noninvasive assessment of left ventricular function, which appears to have become routine, is of value in the appropriate utilization of digoxin, since clinicians' assessment of left ventricular function may be inaccurate. Physicians also do not always discontinue digoxin therapy when indicated.
地高辛是第三大最常处方的药物，但关于其在门诊患者中的使用信息有限。因此，我们对我院242例接受地高辛治疗的门诊患者进行了研究，以评估其使用的合理性，其定义为：（1）当前或既往的室上性心律失常和/或（2）左心室收缩功能障碍（射血分数小于45%）。
获取了242例接受地高辛治疗患者的病历。根据医生所述的地高辛治疗指征将患者分组。仅临床诊断为充血性心力衰竭（CHF）的患者接受超声心动图或放射性核素血管造影以量化左心室收缩功能。有记录的室上性心律失常患者和/或已证实左心室收缩功能障碍的患者被归类为地高辛的合适候选者。
95%的患者因合理指征接受地高辛治疗；75%的患者有已证实的室上性心律失常（27%也患有CHF），20%窦性心律正常的患者有记录的收缩功能障碍。然而，医生在左心室功能的临床评估方面存在困难；根据弗雷明汉评分系统，18%窦性心律且患有CHF的患者以及20%患有室上性心律失常和CHF的患者收缩功能正常。射血分数正常且患有CHF的患者中15%存在S3，射血分数低的患者中69%存在S3；高血压在前一组中明显更常见。97%的患者独立于本研究进行了收缩功能的无创评估，但一些无室上性心律失常且有记录的收缩功能正常的患者仍继续接受该药物治疗。
无创评估左心室功能似乎已成为常规，在合理使用地高辛方面具有价值，因为临床医生对左心室功能的评估可能不准确。医生也并非总是在有指征时停用洋地黄治疗。
