Williamson K M, Patterson J H
School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA.
Ann Pharmacother. 1997 Jul-Aug;31(7-8):888-92. doi: 10.1177/106002809703100716.
The evidence supporting the efficacy of digoxin in patients with heart failure who are in sinus rhythm is substantial. Digoxin improves hemodynamics, exercise capacity, symptoms, and quality of life and reduces hospitalizations. All of this is accomplished with a drug that is very inexpensive and can be given once daily. Its safety has been established through the DIG trial. Although digoxin does not decrease mortality beyond that of diuretics and ACE inhibitors, it does not increase mortality, unlike many positive inotropes. Furthermore, digoxin, in addition to ACE inhibitors and a diuretic, decreases the hospitalization rate due to worsening of heart failure. From a managed care perspective, as well as that of the patient, this is of enormous benefit. A pharmacoeconomic analysis estimated that continuation of digoxin in patients with stable congestive heart failure could save the healthcare system an estimated $ 400 million, based on costs from one hospital. The issue is not whether to use digoxin in these patients, but rather, how early to initiate therapy. From some of the recent data in patients with systolic dysfunction and mild heart failure, as well as knowledge of the neurohormonal activation that occurs early in these patients, it could be suggested that early use of neurohormonal modulators, including digoxin, would decrease the progression of heart failure. Thus, rather than waiting for symptoms despite optimal doses of an ACE inhibitor and diuretic, as suggested by the AHCPR practice guideline for heart failure, initiation of digoxin therapy in patients as early as NYHA class II at a dosage that will achieve a serum concentration of 1.0 ng/mL or less should occur. With the understanding of digoxin's effect on the neurohormonal systems, its role in patients with preserved systolic function needs to be reexplored. The debate can now focus on asymptomatic patients or those with preserved systolic function. Could these patients benefit from therapy with digoxin as well?
支持地高辛对窦性心律的心力衰竭患者有效的证据确凿。地高辛可改善血流动力学、运动能力、症状和生活质量，并减少住院次数。所有这些都是通过一种非常便宜且可每日给药一次的药物实现的。其安全性已通过地高辛干预研究（DIG试验）得到证实。尽管地高辛不会降低死亡率，其效果不超过利尿剂和血管紧张素转换酶（ACE）抑制剂，但与许多正性肌力药物不同，它不会增加死亡率。此外，除ACE抑制剂和利尿剂外，地高辛还可降低因心力衰竭恶化导致的住院率。从管理式医疗的角度以及患者的角度来看，这都有极大的益处。一项药物经济学分析估计，基于一家医院的成本，继续对稳定的充血性心力衰竭患者使用地高辛可为医疗系统节省约4亿美元。问题不在于是否对这些患者使用地高辛，而在于何时尽早开始治疗。从近期关于收缩功能障碍和轻度心力衰竭患者的一些数据，以及对这些患者早期发生的神经激素激活的了解来看，有人可能会提出，早期使用包括地高辛在内的神经激素调节剂会减少心力衰竭的进展。因此，不应像美国医疗保健政策与研究机构（AHCPR）心力衰竭实践指南所建议的那样，在使用了最佳剂量的ACE抑制剂和利尿剂后仍等待症状出现，而应在患者纽约心脏协会（NYHA）心功能分级达到II级时尽早开始地高辛治疗，剂量应使血清浓度达到1.0 ng/mL或更低。随着对地高辛对神经激素系统作用的认识，需要重新探讨其在收缩功能保留患者中的作用。现在争论可以集中在无症状患者或收缩功能保留的患者身上。这些患者也能从地高辛治疗中获益吗？
