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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Despite more than 200 years of research&#44; the role of digoxin in heart failure therapy remains controversial&#46; The American College of Cardiology and American Heart Association &#40;ACC&#47;AHA&#41; guidelines for the management of patients with heart failure &#40;HF&#41; recommend the use of digoxin&#44; unless contraindicated&#44; for persistent symptoms after optimal medical therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Digoxin use is also endorsed by the European Society of Cardiology guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although widely accepted&#44; these recommendations are derived mainly from short-term studies assessing non-mortality outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;8</span></a> The Digitalis Investigator Group &#40;DIG&#41; study&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> a large randomized trial&#44; showed no impact on all-cause or cardiovascular mortality with digoxin in oligosymptomatic male HF patients in sinus rhythm &#40;SR&#41;&#46; However&#44; a reduction in hospitalizations due to worsening HF and an improvement in quality of life were reported&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Two other trials showed that withdrawal of digoxin resulted in worsening HF symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Although more than 90&#37; of patients were receiving angiotensin-converting enzyme inhibitors &#40;ACEIs&#41; in the DIG trial&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> the use of beta-blockers and aldosterone antagonists was not reported and likely was very limited&#46; Similarly&#44; improved outcomes are also seen with cardiac devices&#44; which are now widely used in HF patients&#46; A recently published study suggests no benefit of digoxin in advanced HF patients on contemporary medical therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In this report&#44; HF patients in SR treated with digoxin had a worse prognosis than those who were not&#46; However&#44; this did not appear to be true for patients in atrial fibrillation &#40;AF&#41;&#46; In patients with AF&#44; the beneficial role of digoxin is widely accepted&#44; mainly to optimize ventricular rate control&#44; and the Carvedilol Atrial Fibrillation Evaluation &#40;CAFE&#41; study suggests that there may be synergistic benefits between digoxin and carvedilol&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In our study&#44; we sought to determine the impact of digoxin therapy in advanced HF patients on optimal contemporary medical therapy&#44; and to assess whether prognosis differs according to the presence of AF&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patient population and data collection</span><p id="par0015" class="elsevierStylePara elsevierViewall">This single-center study included 268 consecutive patients admitted to an intensive care unit between January 2003 and June 2006 due to decompensated HF in New York Heart Association &#40;NYHA&#41; class III or IV&#46; Standardized records were used to describe the study population in terms of clinical and demographic characteristics&#44; cardiovascular risk factors and comorbidities&#46; The records also showed HF etiology&#44; hemodynamic status on admission&#44; laboratory parameters&#44; electrocardiographic and echocardiographic data&#44; and treatment&#46; Renal dysfunction was defined as creatinine clearance of &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min calculated by the Cockcroft&#8211;Gault formula&#46; Ischemic cardiomyopathy was defined as left ventricular dysfunction associated with significant coronary disease &#40;&#62;70&#37; stenosis in at least one major epicardial coronary artery and&#47;or &#62;50&#37; left main stenosis&#41;&#46; In the minority of patients without coronary angiography &#40;4&#37;&#41; the diagnostic criterion of ischemic heart disease was prior myocardial infarction &#40;history of infarction or infarct scar on ECG&#41;&#46; Non-ischemic cardiomyopathy was defined as left ventricular dysfunction in the absence of the above alterations&#46; Coronary angiography was performed in 70&#37; of this group&#59; an ischemia stress test &#40;stress echocardiography&#44; myocardial perfusion scanning or perfusion magnetic resonance imaging&#41; was available in the remainder&#44; which revealed no significant alterations&#46; A mean clinical follow-up of 40 months was performed&#46; Clinical data were collected during patients&#8217; visits to the outpatient clinic or by telephone interview&#46; The occurrence of readmission due to decompensated HF and death was recorded&#46; Medical records were reviewed to confirm and to obtain additional information&#46; The population was divided into two groups&#44; according to the presence of AF&#58; group A &#8211; 89 patients with AF and group B &#8211; 179 patients in sinus rhythm&#46; A previously defined subgroup analysis was performed in patients in SR vs&#46; AF&#46; For each group patients medicated and not medicated with digoxin were compared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Endpoints</span><p id="par0020" class="elsevierStylePara elsevierViewall">The primary endpoint was long-term all-cause mortality and the secondary endpoint was a combined outcome of mortality and rehospitalization due to decompensated HF&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">The statistical analysis was performed with SPSS 13&#46;0 for Windows &#40;SPSS Inc&#46;&#44; Chicago&#44; Ill&#46;&#41;&#46; The results were expressed as means &#177; standard deviation for continuous variables and as frequencies and percentages for categorical variables&#46; The frequencies of the categorical variables in the two groups were compared by the chi-square test or Fisher&#39;s exact test&#46; Continuous variables were compared using the Student&#39;s unpaired t test &#40;normal variables&#41; and the Mann&#8211;Whitney U test &#40;non-normal variables&#41;&#46; Kaplan&#8211;Meier survival analysis and the Breslow test were used to compare the groups in terms of cumulative survival&#46; A value of p&#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">General characteristics of the study groups</span><p id="par0030" class="elsevierStylePara elsevierViewall">The baseline characteristics of the study population are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Of the total population hospitalized due to advanced HF during the study period&#44; 33&#46;2&#37; &#40;89&#47;268&#41; presented with AF&#46; These patients were older &#40;62&#46;4&#177;12&#46;8 vs&#46; 55&#46;1&#177;15&#46;4 years&#59; p&#60;0&#46;001&#41;&#44; with higher left ventricular ejection fraction &#40;LVEF&#41; &#40;31&#46;0&#37; vs&#46; 26&#46;0&#37;&#44; p&#61;0&#46;003&#41; and a higher prevalence of valvular disease as HF etiology &#40;3&#46;4&#37; vs&#46; 13&#46;6&#37;&#59; p&#60;0&#46;001&#41;&#46; The prevalence of thyroid disease was higher in AF patients &#40;22&#46;1&#37; vs&#46; 10&#46;3&#37;&#59; p&#61;0&#46;023&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Among the AF patients&#44; there were no significant differences between patients with or without digoxin regarding demographic parameters such as age or gender&#46; We observed a higher prevalence of dyslipidemia in patients not medicated with digoxin &#40;64&#46;7&#37; vs&#46; 31&#46;7&#37;&#44; p&#61;0&#46;039&#41;&#44; but no differences were found between the groups regarding other cardiovascular risk factors or comorbidities&#46; Analysis of hemodynamic&#44; laboratory and echocardiographic data on admission showed no significant differences in blood pressure&#44; heart rate&#44; diuresis rate&#44; LVEF&#44; serum sodium&#44; potassium&#44; hemoglobin and B-type natriuretic peptide &#40;BNP&#41; levels&#44; cardiac output&#44; peak VO<span class="elsevierStyleInf">2</span> or pulmonary artery systolic pressure &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Dilated cardiomyopathy was more frequent in patients on digoxin therapy &#40;86&#46;8&#37; vs&#46; 13&#46;2&#37;&#44; p&#61;0&#46;032&#41; and ischemic cardiomyopathy was more prevalent in patients without this therapy &#40;37&#46;5&#37; vs&#46; 62&#46;5&#37;&#44; p&#60;0&#46;001&#41;&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Concerning group B&#44; no differences were found between patients with or without digoxin regarding demographic parameters&#44; cardiovascular risk factors or comorbidities&#46; LVEF was significantly lower in patients on digoxin therapy &#40;25&#46;0&#37; vs&#46; 30&#46;0&#37;&#44; p&#61;0&#46;003&#41; and admission creatinine was also lower &#40;1&#46;4&#177;0&#46;6 vs&#46; 1&#46;7&#177;1&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#59; p&#61;0&#46;028&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Dilated cardiomyopathy was more frequent in patients on digoxin therapy &#40;57&#46;4&#37; vs&#46; 35&#46;7&#37;&#44; p&#61;0&#46;014&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Therapy</span><p id="par0045" class="elsevierStylePara elsevierViewall">Medications on admission&#44; during hospital stay and at discharge are described in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; AF patients were more often medicated with amiodarone &#40;42&#46;5&#37; vs&#46; 21&#46;0&#37;&#44; p&#61;0&#46;001&#41; and warfarin &#40;50&#46;7&#37; vs&#46; 23&#46;1&#37;&#44; p&#61;0&#46;001&#41; on admission and at discharge &#40;61&#46;8&#37; vs&#46; 43&#46;3&#37;&#59; p&#61;0&#46;004 and 65&#46;2&#37; vs&#46; 34&#46;1&#37;&#59; p&#61;0&#46;001&#44; respectively&#44; for amiodarone and warfarin&#41; and the prescription of beta-blockers was significantly lower &#40;57&#46;3&#37; vs&#46; 83&#46;2&#37;&#59; p&#61;0&#46;001&#41; compared with patients in SR&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In AF patients&#44; spironolactone prescription on admission was higher in patients on digoxin therapy &#40;58&#46;5&#37; vs&#46; 25&#46;0&#37;&#59; p&#61;0&#46;011&#41;&#44; but no differences were found regarding other prior medications or discharge therapy&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding SR patients&#44; we observed that patients on digoxin therapy were more often medicated with spironolactone&#44; furosemide and warfarin prior to hospital admission &#40;67&#46;0&#37; vs&#46; 38&#46;2&#37;&#59; p&#61;0&#46;03&#59; 88&#46;0&#37; vs&#46; 67&#46;6&#37;&#59; p&#61;0&#46;006&#59; 27&#46;5&#37; vs&#46; 8&#46;8&#37;&#59; p&#61;0&#46;024&#44; respectively&#41; and at discharge &#40;91&#46;9&#37; vs&#46; 62&#46;8&#37;&#59; p&#61;0&#46;001&#59; 99&#46;3&#37; vs&#46; 93&#46;0&#37;&#59; p&#61;0&#46;016&#59; 39&#46;0&#37; vs&#46; 18&#46;6&#37;&#59; p&#61;0&#46;014&#44; respectively&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Long-term prognosis</span><p id="par0060" class="elsevierStylePara elsevierViewall">About one-fifth &#40;21&#46;1&#37;&#41; of patients underwent heart transplantation during the follow-up period&#46; Addition of digoxin to contemporary standard HF therapy showed no impact on long-term mortality in patients with advanced HF and SR &#40;19&#46;1&#37; vs&#46; 22&#46;5&#37;&#44; p&#61;0&#46;788&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding AF patients&#44; we observed significantly lower long-term mortality in patients on digoxin therapy &#40;18&#46;6&#37; vs&#46; 46&#46;6&#37;&#44; p&#61;0&#46;048&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Digoxin therapy did not influence the composite endpoint of all-cause mortality and readmissions for decompensated HF&#44; in the total population or stratified by AF&#47;SR&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Despite recent advances in therapy&#44; HF remains associated with high mortality and hospitalization rates&#44; as we report in our contemporary cohort&#46; Digoxin is the oldest HF drug and one of the least expensive&#46; The ACC&#47;AHA HF guidelines recommend considering adding digoxin in patients with persisting HF symptoms already treated with diuretics&#44; an ACEI &#40;or angiotensin receptor blocker&#41; and a beta-blocker&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; there is limited evidence on the role of digoxin in patients on background therapy with beta-blockers and ACEIs&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The landmark DIG study&#44; a randomized controlled trial of digoxin in patients with chronic HF already medicated with diuretics&#44; showed that digoxin had no impact on overall mortality&#44; but did reduce the rate of hospitalizations due to HF&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However&#44; the prescription rate of beta-blockers was not reported and&#44; at the time the trial was conducted&#44; beta-blockers were not accepted as standard therapy for patients with HF&#46; Participants in the DIG trial were male outpatients with chronic stable HF &#40;the majority in NYHA class I or II&#41; in SR&#44; and thus did not reflect real-world HF populations&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Similarly to the DIG trial&#44; we did not see a survival benefit in advanced HF patients in sinus rhythm&#46; However&#44; we failed to demonstrate a reduction in HF hospitalizations&#44; probably due to lack of power&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our population is significantly different from that of the DIG trial&#44; with more severe patients hospitalized for decompensated HF&#44; all in NYHA class III or IV with severely depressed LVEF&#44; and a high prevalence of comorbidities&#46; The severity of this population is highlighted by the significant proportion of patients who ultimately proceeded to heart transplantation&#46; Furthermore&#44; the use of diuretics&#44; ACEIs&#44; beta-blockers and devices in our study population was higher than in other studies examining the role of digoxin&#46; This may have reduced the independent beneficial effect of digoxin on HF readmissions&#46; The same is reported in a substudy of the Valsartan in Heart Failure Trial &#40;Val-HeFT&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In a cohort of 6800 patients&#44; the investigators also failed to show any hospitalization benefit with the use of digoxin therapy&#44; further supporting our results&#46; One relatively recent retrospective study suggests that there was no benefit with digoxin in a heart transplant referral population of 455 patients with advanced HF receiving contemporary medical therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In this study&#44; digoxin use was associated with increased risk of the primary outcome of death&#44; urgent transplantation or ventricular assist device implantation&#44; and the risk was higher in patients in SR compared with AF&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Our study suggests that digoxin therapy may improve the vital prognosis of patients with advanced HF and AF under optimal medical therapy&#46; In AF patients&#44; one potential mechanism of benefit of digoxin is simply to reduce ventricular rate&#44; thereby limiting myocardial oxygen consumption&#44; a concept in which interest was recently reawakened with the publication of the landmark SHIFT trial&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The idea that beta-blockers might eliminate the need for digoxin in patients with AF and HF was the rationale for the CAFE study&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> However&#44; rather than showing that digoxin is redundant&#44; the study suggested that there could be synergistic benefits between digoxin and carvedilol&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">There are reasons other than rate control why digoxin may be more effective in the presence of beta blockade&#46; Beta-blockers&#44; especially nonselective ones&#44; that attenuate stress-induced reductions in serum potassium<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> might neutralize the increase in sudden death associated with the use of digoxin&#46; The inotropic effect of digoxin may improve tolerability to beta-blockers&#44; enabling higher dose titration&#46; Aldosterone antagonists also increase serum potassium&#44; reducing the incidence of hypokalemia&#59; it is well known that sudden death reduction was one of the primary mechanisms of mortality reduction in the Randomized Aldactone Evaluation Study &#40;RALES&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and the EPHESUS trial&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Spironolactone tended to exert a greater reduction in mortality among patients treated with digoxin&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Post-hoc analyses of the DIG trial suggest that digoxin reduced mortality at low &#40;0&#46;5&#8211;0&#46;9<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; serum digoxin concentrations &#40;SDC&#41;&#44; but had no effect at higher &#40;&#8805;1<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; SDC&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> A closer examination of the Kaplan&#8211;Meier survival plots in the DIG trial reveals an early mortality reduction in the digoxin group&#44; followed by a later virtual overlap of the plots&#44; suggesting that&#44; although the early survival benefit was eliminated in later years&#44; there was no increase in mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This lack of a long-term effect of digoxin on mortality may be due to use of open-labeled digoxin in the placebo group&#44; and a cumulative effect of the use of high-dose digoxin&#59; more than 80&#37; of the participants in the DIG trial were receiving &#8805;0&#46;25<span class="elsevierStyleHsp" style=""></span>mg of digoxin daily or matching placebo&#44; which was higher than the currently recommended daily dosage&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In our population&#44; the standard daily dose was 0&#46;125<span class="elsevierStyleHsp" style=""></span>mg&#44; with a majority of patients pausing on weekends&#59; the maximum dose prescribed during data collection was 0&#46;25<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; five times a week&#46; The continued use of high-dose digoxin in elderly patients&#44; with deteriorating kidney function&#44; may have resulted in higher SDC during the later years of the DIG trial&#46; The beneficial effects of digoxin at low SDC are primarily due to its effect on the neurohormonal system&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> By inhibiting the sodium-potassium adenosine triphosphate pump in renal tubules and vagal afferent fibers&#44; digoxin suppresses both the renin-angiotensin-aldosterone and sympathetic nervous systems&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Low SDC also reduces the risk of digoxin toxicity and associated morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Concomitant therapy with beta-blockers and aldosterone antagonists and use of lower doses of digoxin could radically improve the risk&#47;benefit ratio for digoxin&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The explanation for different outcomes in AF and SR remains elusive&#46; In our population&#44; we observed significantly lower LVEF in patients in SR &#40;26&#46;0&#37; vs&#46; 31&#46;0&#37;&#44; p&#61;0&#46;003&#41;&#44; but no other significant differences were found between patients in SR and AF&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; First&#44; this observational retrospective study reflects a single-center experience and includes a relatively small number of patients&#46; Second&#44; we did not have data for SDC&#59; however&#44; the standard dose prescribed was 0&#46;125<span class="elsevierStyleHsp" style=""></span>mg&#47;day five times a week and the maximum dose prescribed during data collection was 0&#46;25<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; and we know that digoxin dose is a strong predictor of SDC&#46; Given the nature of the data set&#44; we were unable to ascertain the length of therapy on digoxin before the index HF admission&#46; Third&#44; data regarding discontinuing or starting therapy&#44; or optimization of drug doses during follow-up&#44; were not available&#46; Previous studies on digoxin in patients with chronic HF reported improvements in LVEF&#44; HF symptoms and exercise performance&#46; In our study&#44; these were not measured&#44; and thus we cannot exclude potential beneficial effects on these soft endpoints&#46; One issue with retrospective outcomes analysis is always whether or not the more severe patients preferentially received a given therapy&#46; However&#44; in our population there were no significant differences between AF patients with or without digoxin regarding demographic parameters&#44; significant comorbidities&#44; or hemodynamic&#44; laboratory&#44; electrocardiographic and echocardiographic data on admission&#44; making selection bias unlikely&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">The present study suggests that digoxin may improve the vital prognosis of AF patients with advanced HF under optimal medical therapy&#46; Digoxin did not demonstrate benefit in patients in SR&#46; These results may help to improve patient selection for treatment with digoxin&#44; in order to achieve a better risk&#47;benefit ratio in advanced HF patients&#46; Polypharmacy is known to be associated with an increased risk of adverse drug reactions&#44; drug interactions and poor compliance&#46; Thus&#44; for multiple reasons of both efficacy and safety&#44; whether or not digoxin therapy has any role in the current management of advanced HF needs to be evaluated&#46; Further randomized controlled trials are required to find out whether digoxin has a role in contemporary management of HF&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Patient population and data collection"
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              "titulo" => "General characteristics of the study groups"
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    "fechaRecibido" => "2011-10-06"
    "fechaAceptado" => "2012-11-05"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Advanced heart failure"
            1 => "Digoxin"
            2 => "Atrial fibrillation"
            3 => "Prognosis"
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          "palabras" => array:4 [
            0 => "Insufici&#234;ncia card&#237;aca avan&#231;ada"
            1 => "Digoxina"
            2 => "Fibrilha&#231;&#227;o auricular"
            3 => "Progn&#243;stico"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The impact of digoxin on outcomes of patients with advanced heart failure &#40;HF&#41; remains uncertain and its effect may be different for patients in atrial fibrillation &#40;AF&#41; or sinus rhythm &#40;SR&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To determine the impact of digoxin on outcomes of advanced HF patients and to assess whether prognosis differs in patients in AF and SR&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 268 consecutive patients admitted to an intensive care unit with decompensated HF were evaluated&#46; Patients were divided into two groups&#58; A &#8211; patients with AF &#40;n&#61;89&#41;&#44; and B &#8211; patients in SR &#40;n&#61;179&#41;&#46; For each group we compared patients medicated and not medicated with digoxin&#46; A mean follow-up of 3&#46;3 years was performed&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Addition of digoxin to contemporary standard HF therapy showed no impact on mortality of patients in group B &#40;all-cause mortality in follow-up&#58; 19&#46;1&#37; vs&#46; 22&#46;5&#37;&#44; p&#61;0&#46;788&#41;&#46; Regarding group A&#44; we observed significantly lower medium-term mortality for patients on digoxin therapy &#40;18&#46;6&#37; vs&#46; 46&#46;6&#37;&#44; p&#61;0&#46;048&#41;&#46; Digoxin therapy did not influence readmissions for decompensated HF&#46; Among AF patients&#44; no differences were found regarding demographic&#44; clinical&#44; echocardiographic and laboratory variables between patients medicated and not medicated with digoxin&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Digoxin therapy may improve the prognosis of advanced HF patients with AF under optimal medical therapy&#46; However&#44; no benefit of digoxin was demonstrated for patients in SR&#46; These results may help to improve patient selection for digoxin therapy&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">O impacto progn&#243;stico da digoxina na insufici&#234;ncia card&#237;aca &#40;IC&#41; avan&#231;ada permanece mal esclarecido&#46; A relev&#226;ncia da terap&#234;utica digit&#225;lica pode ser diferente na fibrilha&#231;&#227;o auricular &#40;FA&#41; relativamente ao ritmo sinusal &#40;RS&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Objectivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Determinar o impacto progn&#243;stico da digoxina na IC e verificar se este &#233; diferente consoante se encontrem em FA ou em RS&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudaram-se 268 doentes internados numa unidade de cuidados intensivos por IC descompensada&#46; Dividiu-se a popula&#231;&#227;o em dois grupos&#58; A &#8211; 89 doentes em FA&#59; grupo B &#8211; 179 doentes em RS&#46; Para cada grupo compararam-se os doentes medicados com os n&#227;o medicados com digoxina&#46; Realizou-se um seguimento cl&#237;nico com a dura&#231;&#227;o mediana de 3&#44;3 anos&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A digoxina n&#227;o teve impacto na mortalidade dos doentes com IC avan&#231;ada que se encontravam em RS &#40;mortalidade a 3&#44;3 anos&#58; 19&#44;1&#37; <span class="elsevierStyleItalic">versus</span> 22&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;788&#41;&#44; adicionada &#224; terap&#234;utica m&#233;dica otimizada&#46; Nos doentes em FA observou-se uma redu&#231;&#227;o significativa da mortalidade nos doentes medicados com digoxina &#40;18&#44;6&#37; <span class="elsevierStyleItalic">versus</span> 46&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;048&#41;&#46; A digoxina n&#227;o alterou a taxa de reinternamentos por IC descompensada&#46; No grupo A n&#227;o se verificaram diferen&#231;as entre os doentes medicados e n&#227;o medicados com digoxina relativamente aos par&#226;metros demogr&#225;ficos&#44; cl&#237;nicos&#44; ecocardiogr&#225;ficos ou laboratoriais&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#227;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Este estudo sugere que a digoxina pode melhorar o progn&#243;stico dos doentes com IC avan&#231;ada e FA&#44; sob terap&#234;utica m&#233;dica optimizada&#46; Contudo&#44; esta n&#227;o demonstrou benef&#237;cio nos doentes em RS&#46; Estes resultados podem contribuir para uma melhor sele&#231;&#227;o dos doentes a medicar com digoxina&#44; otimizando a rela&#231;&#227;o risco&#47;benef&#237;cio desta terap&#234;utica&#46;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">AF&#58; atrial fibrillation&#59; COPD&#58; chronic obstructive pulmonary disease&#59; d&#58; disease&#59; PAD&#58; peripheral arterial disease&#59; SR&#58; sinus rhythm&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sinus rhythm &#40;n&#61;179&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Atrial fibrillation &#40;n&#61;89&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SR vs&#46; AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;078&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;600&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;145&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;749&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;855&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;051&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;524&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;503&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;736&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;114&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;427&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;425&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;651&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;449&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;832&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;860&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;270&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dialysis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;141&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Thyroid d&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;423&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Liver d&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;179&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;111&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;291&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">BNP&#58; B-type natriuretic peptide&#59; CI&#58; cardiac index by the Fick method&#59; Cr&#58; creatinine&#59; DBP&#58; diastolic blood pressure&#59; Hb&#58; hemoglobin&#59; HR&#58; heart rate&#59; LVEF&#58; left ventricular ejection fraction&#59; PASP&#58; pulmonary artery systolic pressure&#59; SBP&#58; systolic blood pressure&#59; VO<span class="elsevierStyleInf">2</span>&#58; peak oxygen uptake&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sinus rhythm &#40;n&#61;179&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Atrial fibrillation &#40;n&#61;89&#41;</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SR vs&#46; AF&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Age&#44; years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">55&#46;08&#177;15&#46;43&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&#46;35&#177;16&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&#177;15&#46;29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;898&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;36&#177;12&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#46;09&#177;12&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;76&#177;12&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVEF&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;26&#177;0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;30&#177;0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;25&#177;0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;31&#177;0&#46;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">SBP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">113&#46;95&#177;23&#46;64&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">117&#46;08&#177;23&#46;74&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">DBP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">HR&#44; bpm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Admission Cr&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Discharge Cr&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Na<span class="elsevierStyleSup">&#43;</span>&#44; mmol&#47;l&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">K<span class="elsevierStyleSup">&#43;</span>&#44; mmol&#47;l&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hb&#44; g&#47;dl&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">BNP&#44; pg&#47;ml&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1000&#46;83&#177;909&#46;93&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1004&#46;75&#177;1186&#46;02&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">999&#46;74&#177;834&#46;34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;987&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;140&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PASP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">VO<span class="elsevierStyleInf">2</span>&#44; ml&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">CI&#44; l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Hospital stay&#44; days&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Blood glucose&#44; mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">125&#46;70&#177;55&#46;96&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;089&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139&#46;74&#177;55&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">135&#46;77&#177;49&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">141&#46;08&#177;57&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;701&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;282&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab355014.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Hemodynamic&#44; echocardiographic and laboratory data&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">AF&#58; atrial fibrillation&#59; SR&#58; sinus rhythm&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sinus rhythm &#40;n&#61;179&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Atrial fibrillation &#40;n&#61;89&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SR vs&#46; AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dilated&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;730&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Restrictive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;072&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;074&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertrophic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;428&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;395&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;500&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ischemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">15&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">25&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Valvulopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;165&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;422&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab355017.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Etiology of heart failure&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">ACEI&#58; angiotensin-converting enzyme inhibitor&#59; AF&#58; atrial fibrillation&#59; ARB&#58; angiotensin receptor blocker&#59; IV&#58; intravenous&#59; SR&#58; sinus rhythm&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Medication&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Sinus rhythm &#40;n&#61;179&#41;</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Atrial fibrillation &#40;n&#61;89&#41;</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Total &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No digoxin &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Total &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Journal Information
Vol. 32. Issue 4.
Pages 303-310 (April 2013)
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Vol. 32. Issue 4.
Pages 303-310 (April 2013)
Original article
Open Access
Digoxin in advanced heart failure patients: A question of rhythm
Digoxina na insuficiência cardíaca avançada: uma questão de ritmo
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7336
Elisabete Jorge
Corresponding author
elisabetejorge@gmail.com

Corresponding author.
, Rui Baptista, Hélia Martins, Fátima Saraiva, Susana Costa, Henrique Vieira, Lourenço Coelho, Pedro Monteiro, Fátima Franco, Luís A. Providência
Hospitais da Universidade de Coimbra e Clínica Universitária de Cardiologia da Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
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Abstract
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Figures (2)
Tables (4)
Table 1. General characteristics of the study population.
Table 2. Hemodynamic, echocardiographic and laboratory data.
Table 3. Etiology of heart failure.
Table 4. Medication on admission, during hospital stay and at discharge.
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Abstract
Background

The impact of digoxin on outcomes of patients with advanced heart failure (HF) remains uncertain and its effect may be different for patients in atrial fibrillation (AF) or sinus rhythm (SR).

Objectives

To determine the impact of digoxin on outcomes of advanced HF patients and to assess whether prognosis differs in patients in AF and SR.

Methods

A total of 268 consecutive patients admitted to an intensive care unit with decompensated HF were evaluated. Patients were divided into two groups: A – patients with AF (n=89), and B – patients in SR (n=179). For each group we compared patients medicated and not medicated with digoxin. A mean follow-up of 3.3 years was performed.

Results

Addition of digoxin to contemporary standard HF therapy showed no impact on mortality of patients in group B (all-cause mortality in follow-up: 19.1% vs. 22.5%, p=0.788). Regarding group A, we observed significantly lower medium-term mortality for patients on digoxin therapy (18.6% vs. 46.6%, p=0.048). Digoxin therapy did not influence readmissions for decompensated HF. Among AF patients, no differences were found regarding demographic, clinical, echocardiographic and laboratory variables between patients medicated and not medicated with digoxin.

Conclusions

Digoxin therapy may improve the prognosis of advanced HF patients with AF under optimal medical therapy. However, no benefit of digoxin was demonstrated for patients in SR. These results may help to improve patient selection for digoxin therapy.

Keywords:
Advanced heart failure
Digoxin
Atrial fibrillation
Prognosis
Resumo
Introdução

O impacto prognóstico da digoxina na insuficiência cardíaca (IC) avançada permanece mal esclarecido. A relevância da terapêutica digitálica pode ser diferente na fibrilhação auricular (FA) relativamente ao ritmo sinusal (RS).

Objectivos

Determinar o impacto prognóstico da digoxina na IC e verificar se este é diferente consoante se encontrem em FA ou em RS.

Métodos

Estudaram-se 268 doentes internados numa unidade de cuidados intensivos por IC descompensada. Dividiu-se a população em dois grupos: A – 89 doentes em FA; grupo B – 179 doentes em RS. Para cada grupo compararam-se os doentes medicados com os não medicados com digoxina. Realizou-se um seguimento clínico com a duração mediana de 3,3 anos.

Resultados

A digoxina não teve impacto na mortalidade dos doentes com IC avançada que se encontravam em RS (mortalidade a 3,3 anos: 19,1% versus 22,5%, p=0,788), adicionada à terapêutica médica otimizada. Nos doentes em FA observou-se uma redução significativa da mortalidade nos doentes medicados com digoxina (18,6% versus 46,6%, p=0,048). A digoxina não alterou a taxa de reinternamentos por IC descompensada. No grupo A não se verificaram diferenças entre os doentes medicados e não medicados com digoxina relativamente aos parâmetros demográficos, clínicos, ecocardiográficos ou laboratoriais.

Conclusão

Este estudo sugere que a digoxina pode melhorar o prognóstico dos doentes com IC avançada e FA, sob terapêutica médica optimizada. Contudo, esta não demonstrou benefício nos doentes em RS. Estes resultados podem contribuir para uma melhor seleção dos doentes a medicar com digoxina, otimizando a relação risco/benefício desta terapêutica.

Palavras-chave:
Insuficiência cardíaca avançada
Digoxina
Fibrilhação auricular
Prognóstico
Full Text
Introduction

Despite more than 200 years of research, the role of digoxin in heart failure therapy remains controversial. The American College of Cardiology and American Heart Association (ACC/AHA) guidelines for the management of patients with heart failure (HF) recommend the use of digoxin, unless contraindicated, for persistent symptoms after optimal medical therapy.1 Digoxin use is also endorsed by the European Society of Cardiology guidelines.2 Although widely accepted, these recommendations are derived mainly from short-term studies assessing non-mortality outcomes.3–8 The Digitalis Investigator Group (DIG) study,9 a large randomized trial, showed no impact on all-cause or cardiovascular mortality with digoxin in oligosymptomatic male HF patients in sinus rhythm (SR). However, a reduction in hospitalizations due to worsening HF and an improvement in quality of life were reported.10 Two other trials showed that withdrawal of digoxin resulted in worsening HF symptoms.6,7 Although more than 90% of patients were receiving angiotensin-converting enzyme inhibitors (ACEIs) in the DIG trial,9 the use of beta-blockers and aldosterone antagonists was not reported and likely was very limited. Similarly, improved outcomes are also seen with cardiac devices, which are now widely used in HF patients. A recently published study suggests no benefit of digoxin in advanced HF patients on contemporary medical therapy.11 In this report, HF patients in SR treated with digoxin had a worse prognosis than those who were not. However, this did not appear to be true for patients in atrial fibrillation (AF). In patients with AF, the beneficial role of digoxin is widely accepted, mainly to optimize ventricular rate control, and the Carvedilol Atrial Fibrillation Evaluation (CAFE) study suggests that there may be synergistic benefits between digoxin and carvedilol.11

In our study, we sought to determine the impact of digoxin therapy in advanced HF patients on optimal contemporary medical therapy, and to assess whether prognosis differs according to the presence of AF.

MethodsPatient population and data collection

This single-center study included 268 consecutive patients admitted to an intensive care unit between January 2003 and June 2006 due to decompensated HF in New York Heart Association (NYHA) class III or IV. Standardized records were used to describe the study population in terms of clinical and demographic characteristics, cardiovascular risk factors and comorbidities. The records also showed HF etiology, hemodynamic status on admission, laboratory parameters, electrocardiographic and echocardiographic data, and treatment. Renal dysfunction was defined as creatinine clearance of <60ml/min calculated by the Cockcroft–Gault formula. Ischemic cardiomyopathy was defined as left ventricular dysfunction associated with significant coronary disease (>70% stenosis in at least one major epicardial coronary artery and/or >50% left main stenosis). In the minority of patients without coronary angiography (4%) the diagnostic criterion of ischemic heart disease was prior myocardial infarction (history of infarction or infarct scar on ECG). Non-ischemic cardiomyopathy was defined as left ventricular dysfunction in the absence of the above alterations. Coronary angiography was performed in 70% of this group; an ischemia stress test (stress echocardiography, myocardial perfusion scanning or perfusion magnetic resonance imaging) was available in the remainder, which revealed no significant alterations. A mean clinical follow-up of 40 months was performed. Clinical data were collected during patients’ visits to the outpatient clinic or by telephone interview. The occurrence of readmission due to decompensated HF and death was recorded. Medical records were reviewed to confirm and to obtain additional information. The population was divided into two groups, according to the presence of AF: group A – 89 patients with AF and group B – 179 patients in sinus rhythm. A previously defined subgroup analysis was performed in patients in SR vs. AF. For each group patients medicated and not medicated with digoxin were compared.

Endpoints

The primary endpoint was long-term all-cause mortality and the secondary endpoint was a combined outcome of mortality and rehospitalization due to decompensated HF.

Statistical analysis

The statistical analysis was performed with SPSS 13.0 for Windows (SPSS Inc., Chicago, Ill.). The results were expressed as means ± standard deviation for continuous variables and as frequencies and percentages for categorical variables. The frequencies of the categorical variables in the two groups were compared by the chi-square test or Fisher's exact test. Continuous variables were compared using the Student's unpaired t test (normal variables) and the Mann–Whitney U test (non-normal variables). Kaplan–Meier survival analysis and the Breslow test were used to compare the groups in terms of cumulative survival. A value of p<0.05 was considered statistically significant.

ResultsGeneral characteristics of the study groups

The baseline characteristics of the study population are listed in Table 1. Of the total population hospitalized due to advanced HF during the study period, 33.2% (89/268) presented with AF. These patients were older (62.4±12.8 vs. 55.1±15.4 years; p<0.001), with higher left ventricular ejection fraction (LVEF) (31.0% vs. 26.0%, p=0.003) and a higher prevalence of valvular disease as HF etiology (3.4% vs. 13.6%; p<0.001). The prevalence of thyroid disease was higher in AF patients (22.1% vs. 10.3%; p=0.023).

Table 1.

General characteristics of the study population.

(%)  Sinus rhythm (n=179)Atrial fibrillation (n=89)SR vs. AF 
  No digoxin  Digoxin  Total  No digoxin  Digoxin  Total 
Male  62.8  76.5  73.2  0.078  95.7  69.7  76.4  0.012  0.600 
Anemia  28.1  16.5  19.3  0.145  15.8  19.1  18.2  0.749  0.855 
Dyslipidemia  54.8  35.5  39.7  0.051  52.4  28.0  35.2  0.500  0.524 
COPD  18.2  13.5  14.6  0.503  26.3  31.3  68.8  0.736  0.114 
Diabetes  36.4  29.1  30.8  0.427  26.3  36.4  33.8  0.425  0.651 
Stroke  10.0  6.0  6.9  0.449  5.3  6.7  6.3  0.832  0.860 
PAD  13.8  15.5  15.1  0.825  5.6  15.9  12.9  0.270  0.689 
Dialysis  2.4  2.9  2.8  0.666  0.0  4.5  3.4  0.141  0.968 
Thyroid d.  6.5  11.4  10.3  0.423  0.0  29.4  22.1  0.011  0.023 
Liver d.  0.0  5.9  4.6  0.179  5.6  0.0  1.6  0.111  0.291 

AF: atrial fibrillation; COPD: chronic obstructive pulmonary disease; d: disease; PAD: peripheral arterial disease; SR: sinus rhythm.

Among the AF patients, there were no significant differences between patients with or without digoxin regarding demographic parameters such as age or gender. We observed a higher prevalence of dyslipidemia in patients not medicated with digoxin (64.7% vs. 31.7%, p=0.039), but no differences were found between the groups regarding other cardiovascular risk factors or comorbidities. Analysis of hemodynamic, laboratory and echocardiographic data on admission showed no significant differences in blood pressure, heart rate, diuresis rate, LVEF, serum sodium, potassium, hemoglobin and B-type natriuretic peptide (BNP) levels, cardiac output, peak VO2 or pulmonary artery systolic pressure (Table 2). Dilated cardiomyopathy was more frequent in patients on digoxin therapy (86.8% vs. 13.2%, p=0.032) and ischemic cardiomyopathy was more prevalent in patients without this therapy (37.5% vs. 62.5%, p<0.001), as shown in Table 3.

Table 2.

Hemodynamic, echocardiographic and laboratory data.

  Sinus rhythm (n=179)Atrial fibrillation (n=89)SR vs. AF 
  Total  No digoxin  Digoxin  Total  No digoxin  Digoxin 
Age, years  55.08±15.43  55.35±16.04  55±15.29  0.898  62.36±12.81  64.09±12.99  61.76±12.8  0.456  <0.001 
LVEF, %  0.26±0.1  0.30±0.12  0.25±0.08  0.003  0.31±0.12  0.31±0.13  0.30±0.12  0.746  0.003 
SBP, mmHg  113.95±23.64  119.15±27.49  112.43±22.28  0.146  117.08±23.74  120.43±26.6  116.29±23.18  0.561  0.540 
DBP, mmHg  68.93±14.74  72.53±16.35  67.87±14.14  0.105  70.37±16.36  73.93±13.6  69.53±16.94  0.369  0.727 
HR, bpm  84.72±20.3  84.79±19.32  84.7±20.65  0.981  89.19±21.38  86.21±19.03  89.9±22  0.566  0.011 
Admission Cr, mg/dl  1.42±0.74  1.68±1.13  1.35±0.58  0.028  1.59±0.97  1.66±0.67  1.57±1.04  0.749  0.353 
Discharge Cr, mg/dl  1.42±0.68  1.59±0.88  1.37±0.61  0.106  1.46±0.84  1.61±0.69  1.42±0.88  0.438  0.704 
Na+, mmol/l  136.89±5.32  138.34±3.68  136.5±5.63  0.082  135.97±5.64  136.33±6.99  135.88±5.31  0.783  0.047 
K+, mmol/l  4.38±0.72  4.43±0.7  4.36±0.73  0.600  4.28±0.64  4.03±0.77  4.35±0.59  0.090  0.403 
Hb, g/dl  13.19±2.14  12.79±1.89  13.29±2.2  0.267  13.4±2.22  12.96±2.46  13.5±2.17  0.435  0.489 
BNP, pg/ml  1354.25±1251.43  1408.58±1242.94  1339.22±1259.98  0.804  1000.83±909.93  1004.75±1186.02  999.74±834.34  0.987  0.140 
PASP, mmHg  50.67±16.47  40.55±17.17  48.77±18.65  0.187  47.59±11.56  65±18.91  53.24±19.2  0.232  0.153 
VO2, ml/kg/min  17.25±4.38  18.28±4.26  17.04±4.4  0.290  15.59±4.37  17.07±2.84  15.25±4.63  0.366  0.081 
CI, l/min/m2  2.04±0.51  2.23±0.48  1.99±0.51  0.164  2.15±1.12  2.85±2.3  1.96±0.41  0.082  0.672 
Hospital stay, days  5.94±4.37  7.02±6.23  5.60±3.55  0.062  6.84±4.67  6.09±4.28  7.11±4.8  0.371  0.032 
Blood glucose, mg/dl  130.01±60.01  143.74±70.41  125.70±55.96  0.089  139.74±55.45  135.77±49.72  141.08±57.55  0.701  0.282 

BNP: B-type natriuretic peptide; CI: cardiac index by the Fick method; Cr: creatinine; DBP: diastolic blood pressure; Hb: hemoglobin; HR: heart rate; LVEF: left ventricular ejection fraction; PASP: pulmonary artery systolic pressure; SBP: systolic blood pressure; VO2: peak oxygen uptake.

Table 3.

Etiology of heart failure.

(%)  Sinus rhythm (n=179)Atrial fibrillation (n=89)SR vs. AF 
  No digoxin  Digoxin  Total  No digoxin  Digoxin  Total 
Dilated  35.7  57.4  52.2  0.014  21.7  60.0  50.0  0.002  0.730 
Restrictive  2.4  0.0  0.6  0.072  8.7  1.5  3.4  0.104  0.074 
Hypertrophic  0.0  1.5  1.1  0.428  0.0  3.1  2.3  0.395  0.500 
Ischemic  47.6  34.6  37.6  0.127  52.2  15.4  25.0  0.001  0.400 
Valvulopathy  0.0  4.4  3.4  0.165  8.7  15.4  13.6  0.422  <0.001 

AF: atrial fibrillation; SR: sinus rhythm.

Concerning group B, no differences were found between patients with or without digoxin regarding demographic parameters, cardiovascular risk factors or comorbidities. LVEF was significantly lower in patients on digoxin therapy (25.0% vs. 30.0%, p=0.003) and admission creatinine was also lower (1.4±0.6 vs. 1.7±1.1mg/dl; p=0.028) (Table 2). Dilated cardiomyopathy was more frequent in patients on digoxin therapy (57.4% vs. 35.7%, p=0.014) (Table 3).

Therapy

Medications on admission, during hospital stay and at discharge are described in Table 4. AF patients were more often medicated with amiodarone (42.5% vs. 21.0%, p=0.001) and warfarin (50.7% vs. 23.1%, p=0.001) on admission and at discharge (61.8% vs. 43.3%; p=0.004 and 65.2% vs. 34.1%; p=0.001, respectively, for amiodarone and warfarin) and the prescription of beta-blockers was significantly lower (57.3% vs. 83.2%; p=0.001) compared with patients in SR.

Table 4.

Medication on admission, during hospital stay and at discharge.

Medication  Sinus rhythm (n=179)Atrial fibrillation (n=89)SR vs. AF 
  No digoxin (%)  Digoxin (%)  Total (%)  No digoxin (%)  Digoxin (%)  Total (%) 
Admission
ACEI  67.6  63.3  64.3  0.644  55.0  71.7  67.1  0.176  0.684 
ARB  5.9  14.7  12.6  0.177  20.0  17.0  17.8  0.764  0.391 
Beta-blocker  44.1  57.8  54.5  0.162  40.0  47.2  45.2  0.583  0.194 
Spironolactone  38.2  67.0  60.1  0.003  25.0  58.5  49.3  0.011  0.129 
Digoxin  11.8  52.3  42.7  <0.001  10.0  67.9  52.1  <0.001  0.190 
Furosemide  67.6  88.0  83.1  0.006  85.0  88.7  87.7  0.670  0.378 
Amiodarone  17.6  22.0  21.0  0.585  45.0  41.5  42.5  0.788  <0.001 
Statin  32.4  21.1  23.8  0.178  25.0  17.0  19.2  0.438  0.442 
Warfarin  8.8  27.5  23.1  0.024  40.0  54.7  50.7  0.262  <0.001 
In-hospital
Dobutamine  14.3  18.5  17.5  0.528  8.7  21.2  18.0  0.178  0.926 
Dopamine  9.5  11.1  10.7  0.772  17.4  9.1  11.2  0.278  0.901 
Noradrenaline  2.4  0.7  1.1  0.380  0.0  3.0  2.2  0.398  0.480 
IV amiodarone  23.1  21.2  21.7  0.890  25.0  25.0  25.0  1.000  0.758 
Levosimendan  67.4  81.5  78.1  0.053  56.5  80.0  73.9  0.028  0.443 
Discharge
ACEI  79.1  82.2  81.5  0.643  65.2  78.5  75.0  0.207  0.221 
ARB  14.0  14.9  14.7  0.876  17.4  21.2  20.2  0.694  0.252 
Beta-blocker  81.4  83.8  83.2  0.710  52.2  59.1  57.3  0.564  <0.001 
Spironolactone  62.8  91.9  84.9  <0.001  82.6  86.4  85.4  0.661  0.918 
Furosemide  93.0  99.3  97.8  0.016  100.0  98.5  98.9  0.553  0.527 
Amiodarone  38.1  44.9  43.3  0.440  47.8  66.7  61.8  0.109  0.004 
Statin  46.5  31.6  31.7  0.075  26.1  22.7  23.6  0.744  0.054 
Warfarin  18.6  39.0  34.1  0.014  65.2  65.2  65.2  0.995  <0.001 

ACEI: angiotensin-converting enzyme inhibitor; AF: atrial fibrillation; ARB: angiotensin receptor blocker; IV: intravenous; SR: sinus rhythm.

In AF patients, spironolactone prescription on admission was higher in patients on digoxin therapy (58.5% vs. 25.0%; p=0.011), but no differences were found regarding other prior medications or discharge therapy.

Regarding SR patients, we observed that patients on digoxin therapy were more often medicated with spironolactone, furosemide and warfarin prior to hospital admission (67.0% vs. 38.2%; p=0.03; 88.0% vs. 67.6%; p=0.006; 27.5% vs. 8.8%; p=0.024, respectively) and at discharge (91.9% vs. 62.8%; p=0.001; 99.3% vs. 93.0%; p=0.016; 39.0% vs. 18.6%; p=0.014, respectively).

Long-term prognosis

About one-fifth (21.1%) of patients underwent heart transplantation during the follow-up period. Addition of digoxin to contemporary standard HF therapy showed no impact on long-term mortality in patients with advanced HF and SR (19.1% vs. 22.5%, p=0.788) (Figure 1).

Figure 1.

Cumulative 40-month survival in patients in sinus rhythm stratified according to digoxin medication.

(0.14MB).

Regarding AF patients, we observed significantly lower long-term mortality in patients on digoxin therapy (18.6% vs. 46.6%, p=0.048) (Figure 2). Digoxin therapy did not influence the composite endpoint of all-cause mortality and readmissions for decompensated HF, in the total population or stratified by AF/SR.

Figure 2.

Cumulative 40-month survival in patients with atrial fibrillation stratified according to digoxin medication.

(0.14MB).
Discussion

Despite recent advances in therapy, HF remains associated with high mortality and hospitalization rates, as we report in our contemporary cohort. Digoxin is the oldest HF drug and one of the least expensive. The ACC/AHA HF guidelines recommend considering adding digoxin in patients with persisting HF symptoms already treated with diuretics, an ACEI (or angiotensin receptor blocker) and a beta-blocker.1 However, there is limited evidence on the role of digoxin in patients on background therapy with beta-blockers and ACEIs.

The landmark DIG study, a randomized controlled trial of digoxin in patients with chronic HF already medicated with diuretics, showed that digoxin had no impact on overall mortality, but did reduce the rate of hospitalizations due to HF.9 However, the prescription rate of beta-blockers was not reported and, at the time the trial was conducted, beta-blockers were not accepted as standard therapy for patients with HF. Participants in the DIG trial were male outpatients with chronic stable HF (the majority in NYHA class I or II) in SR, and thus did not reflect real-world HF populations.9 Similarly to the DIG trial, we did not see a survival benefit in advanced HF patients in sinus rhythm. However, we failed to demonstrate a reduction in HF hospitalizations, probably due to lack of power.

Our population is significantly different from that of the DIG trial, with more severe patients hospitalized for decompensated HF, all in NYHA class III or IV with severely depressed LVEF, and a high prevalence of comorbidities. The severity of this population is highlighted by the significant proportion of patients who ultimately proceeded to heart transplantation. Furthermore, the use of diuretics, ACEIs, beta-blockers and devices in our study population was higher than in other studies examining the role of digoxin. This may have reduced the independent beneficial effect of digoxin on HF readmissions. The same is reported in a substudy of the Valsartan in Heart Failure Trial (Val-HeFT).12 In a cohort of 6800 patients, the investigators also failed to show any hospitalization benefit with the use of digoxin therapy, further supporting our results. One relatively recent retrospective study suggests that there was no benefit with digoxin in a heart transplant referral population of 455 patients with advanced HF receiving contemporary medical therapy.13 In this study, digoxin use was associated with increased risk of the primary outcome of death, urgent transplantation or ventricular assist device implantation, and the risk was higher in patients in SR compared with AF.

Our study suggests that digoxin therapy may improve the vital prognosis of patients with advanced HF and AF under optimal medical therapy. In AF patients, one potential mechanism of benefit of digoxin is simply to reduce ventricular rate, thereby limiting myocardial oxygen consumption, a concept in which interest was recently reawakened with the publication of the landmark SHIFT trial.14 The idea that beta-blockers might eliminate the need for digoxin in patients with AF and HF was the rationale for the CAFE study.11 However, rather than showing that digoxin is redundant, the study suggested that there could be synergistic benefits between digoxin and carvedilol.

There are reasons other than rate control why digoxin may be more effective in the presence of beta blockade. Beta-blockers, especially nonselective ones, that attenuate stress-induced reductions in serum potassium15 might neutralize the increase in sudden death associated with the use of digoxin. The inotropic effect of digoxin may improve tolerability to beta-blockers, enabling higher dose titration. Aldosterone antagonists also increase serum potassium, reducing the incidence of hypokalemia; it is well known that sudden death reduction was one of the primary mechanisms of mortality reduction in the Randomized Aldactone Evaluation Study (RALES)16 and the EPHESUS trial.17 Spironolactone tended to exert a greater reduction in mortality among patients treated with digoxin.

Post-hoc analyses of the DIG trial suggest that digoxin reduced mortality at low (0.5–0.9ng/ml) serum digoxin concentrations (SDC), but had no effect at higher (≥1ng/ml) SDC.18 A closer examination of the Kaplan–Meier survival plots in the DIG trial reveals an early mortality reduction in the digoxin group, followed by a later virtual overlap of the plots, suggesting that, although the early survival benefit was eliminated in later years, there was no increase in mortality.19 This lack of a long-term effect of digoxin on mortality may be due to use of open-labeled digoxin in the placebo group, and a cumulative effect of the use of high-dose digoxin; more than 80% of the participants in the DIG trial were receiving ≥0.25mg of digoxin daily or matching placebo, which was higher than the currently recommended daily dosage.18 In our population, the standard daily dose was 0.125mg, with a majority of patients pausing on weekends; the maximum dose prescribed during data collection was 0.25mg/day, five times a week. The continued use of high-dose digoxin in elderly patients, with deteriorating kidney function, may have resulted in higher SDC during the later years of the DIG trial. The beneficial effects of digoxin at low SDC are primarily due to its effect on the neurohormonal system.18 By inhibiting the sodium-potassium adenosine triphosphate pump in renal tubules and vagal afferent fibers, digoxin suppresses both the renin-angiotensin-aldosterone and sympathetic nervous systems.18 Low SDC also reduces the risk of digoxin toxicity and associated morbidity and mortality.18 Concomitant therapy with beta-blockers and aldosterone antagonists and use of lower doses of digoxin could radically improve the risk/benefit ratio for digoxin.20

The explanation for different outcomes in AF and SR remains elusive. In our population, we observed significantly lower LVEF in patients in SR (26.0% vs. 31.0%, p=0.003), but no other significant differences were found between patients in SR and AF.

Our study has several limitations. First, this observational retrospective study reflects a single-center experience and includes a relatively small number of patients. Second, we did not have data for SDC; however, the standard dose prescribed was 0.125mg/day five times a week and the maximum dose prescribed during data collection was 0.25mg/day, and we know that digoxin dose is a strong predictor of SDC. Given the nature of the data set, we were unable to ascertain the length of therapy on digoxin before the index HF admission. Third, data regarding discontinuing or starting therapy, or optimization of drug doses during follow-up, were not available. Previous studies on digoxin in patients with chronic HF reported improvements in LVEF, HF symptoms and exercise performance. In our study, these were not measured, and thus we cannot exclude potential beneficial effects on these soft endpoints. One issue with retrospective outcomes analysis is always whether or not the more severe patients preferentially received a given therapy. However, in our population there were no significant differences between AF patients with or without digoxin regarding demographic parameters, significant comorbidities, or hemodynamic, laboratory, electrocardiographic and echocardiographic data on admission, making selection bias unlikely.

Conclusions

The present study suggests that digoxin may improve the vital prognosis of AF patients with advanced HF under optimal medical therapy. Digoxin did not demonstrate benefit in patients in SR. These results may help to improve patient selection for treatment with digoxin, in order to achieve a better risk/benefit ratio in advanced HF patients. Polypharmacy is known to be associated with an increased risk of adverse drug reactions, drug interactions and poor compliance. Thus, for multiple reasons of both efficacy and safety, whether or not digoxin therapy has any role in the current management of advanced HF needs to be evaluated. Further randomized controlled trials are required to find out whether digoxin has a role in contemporary management of HF.

Conflicts of interest

The authors have no conflicts of interest to declare.

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