Safety of Transvenous Temporary Cardiac Pacing in Patients with Accidental Digoxin Overdose and Symptomatic Bradycardia

Abstract

Background: Patients with digoxin intoxication may need transvenous temporary cardiac pacing (TCP) when symptomatic bradyarrhythmias are present. However, it has been reported that TCP might be associated with fatal arrhythmias in patients with acute digitalis intoxication caused by attempted suicide. The aim of this study was to assess the safety of TCP in patients with accidental digoxin-related symptomatic bradyarrhythmias. Materials and Methods: Seventy patients (30 men; age 74 ± 12 years) were enrolled in this retrospective study. Patients were divided into two groups: group 1 with TCP and group 2 without TCP. A digoxin overdose was defined as a serum digoxin level higher than 2.0 ng/ml combined with the presence of digoxin-related symptoms. Detailed clinical characteristics were reviewed on the basis of the medical records. Results: Group 1 included 24 patients (34.3%, 10 men). The rhythms prior to pacemaker insertion in group 1 included sinus arrest with junctional bradyarrhythmias (n = 9), atrial fibrillation with a slow ventricular rate (n = 11), and high-degree atrioventricular block (n = 4). The mean duration of pacemaker implantation was 5.8 ± 2.9 days (2–12 days). There was no major arrhythmic event or mortality after TCP in group 1. Two patients in group 2 (4%) died of ventricular tachyarrhythmias. Group 1 had a higher level of blood urea nitrogen (45.1 ± 26.0 vs. 33.4 ± 19.3 mg/dl), of left ventricular ejection fraction (68 vs. 56%), and of digoxin (4.4 ± 2.1 vs. 3.4 ± 1.3 ng/ml) but a lower serum calcium level (8.7 ± 0.6 vs. 9.1 ± 0.8 mg/dl). Conclusion: TCP was safe for patients with a digoxin overdose complicated by symptomatic bradycardia and should be recommended in such situations. However, this conclusion does not apply to acute digoxin intoxication as a result of attempted suicide.

A Case Report on Chronic Digoxin Toxicity

“…Management of arrhythmias is shown in figure 3.The use of pacemakers has very limited indications, since they do not guarantee control of rhythm disorders, and intra-cardiac placement is nowadays totally contraindicated, especially in acute poisoning, since they can induce malignant arrhythmias 13 . But some authors have obtained good results in cases of chronic poisoning, and recommend temporary pacemakers in patients with advanced AVB or symptomatic bradycardia, programmed at low frequencies (55-60 beats/min) to minimize their arrhythmogenic effect 14 .…”

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

“…Case reports and case series support a role for pacing as temporizing therapy. 15,17–20,26,29,30,58,65,66 However, iatrogenic complications from transvenous pacing are common 63 and were reported in 36% of patients in 1 series. 67 Some patients required a higher-than-normal current, and in some cases, pacing could not be successfully resumed after interruption.…”

Forensic, legal, and clinical aspects of deaths associated with implanted cardiac devices

“…The other articles mostly dealt with the therapeutic use of pacemakers in the treatment of individuals after they have attempted suicide by various substances such as thioridazine ( 50 ), nebivolol ( 51 ), or propafenone and captopril ( 52 ). Also, ethical aspects in end-of-life-scenarios [e.g., ( 53 , 54 )], or therapeutic aspects in accidental digoxin overdosing ( 55 ) are discussed in the literature. However, 8 articles deal with suicide attempts by targeting the aggregate and/or the leads ( 35 , 42 , 43 , 45 – 49 ).…”