From the Guidelines
Digoxin is contraindicated in bradycardia due to its potential to further slow the heart rate and worsen symptoms. Patients with bradycardia (heart rate below 60 beats per minute) should not be given digoxin because this medication can lead to dangerous or life-threatening arrhythmias 1. According to the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay, digoxin Fab antibody fragment is reasonable to increase heart rate and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise in the setting of digoxin toxicity 1.
Key Considerations
- Digoxin works by inhibiting the sodium-potassium ATPase pump in cardiac cells, which increases intracellular calcium and enhances cardiac contractility while simultaneously slowing conduction through the AV node 1.
- This slowing effect on the heart's electrical conduction system is particularly problematic in patients who already have a slow heart rate.
- Alternative medications should be considered for patients with heart failure or atrial fibrillation who also have bradycardia.
- If a patient on digoxin develops bradycardia, the medication should be held and the patient should be evaluated promptly 1.
- Serum digoxin levels may need to be checked to rule out toxicity, especially in elderly patients or those with renal impairment who are at higher risk of accumulating toxic levels of the drug 1.
Management of Digoxin-Induced Bradycardia
- In patients with bradycardia associated with symptoms or hemodynamic compromise attributable to digoxin toxicity, digoxin Fab antibody fragment is recommended to increase heart rate and improve symptoms 1.
- Dialysis is not recommended for removal of digoxin in patients with bradycardia associated with symptoms or hemodynamic compromise attributable to digoxin toxicity 1.
From the FDA Drug Label
Because digoxin slows sinoatrial and AV conduction, the drug commonly prolongs the PR interval. The drug may cause severe sinus bradycardia or sinoatrial block in patients with pre-existing sinus node disease and may cause advanced or complete heart block in patients with pre-existing incomplete AV block
- Contraindication: The FDA drug label does not explicitly state that digoxin is contraindicated in bradycardia, but it does warn that the drug may cause severe sinus bradycardia or sinoatrial block in patients with pre-existing sinus node disease.
- Clinical Decision: Based on the available information, digoxin should be used with caution in patients with bradycardia, especially those with pre-existing sinus node disease, as it may worsen the condition 2.
From the Research
Digoxin Contraindications
- Digoxin is contraindicated in patients with certain conditions, including:
- Ventricular fibrillation
- Hypersensitivity to digoxin
- Hyperkalemia
- However, the provided studies do not directly address whether digoxin is contraindicated in bradycardia.
Bradycardia and Digoxin
- Bradycardia is a condition characterized by a slow heart rate, typically less than 60 beats per minute.
- Digoxin can actually cause bradycardia as a side effect, particularly at toxic levels 3.
- There is no direct evidence in the provided studies to suggest that digoxin is contraindicated in bradycardia, but its use may exacerbate the condition.
Alternative Treatments
- For patients with atrial fibrillation and heart failure, beta-blockers are often preferred over digoxin due to their more favorable safety profile 4, 5.
- The choice of treatment ultimately depends on the individual patient's condition and medical history, and should be made under the guidance of a healthcare professional.