Use of Digoxin in Severe Acute Heart Failure with Refractory Sinus Tachycardia

A 45-year-old man was admitted to our hospital with orthopnea, edema, bilateral congestion on chest X-ray and elevated BNP level (764 pg/ml). The electrocardiogram showed sinus tachycardia with a heart rate (HR) of 113 bpm. An echocardiogram revealed a dilated left ventricle with an ejection fraction of 16%. After administration of diuretics as initial HF therapy, his symptoms, pulmonary congestion and BNP level improved, whereas his HR remained above 100 bpm. He was diagnosed with idiopathic dilated cardiomyopathy after completing appropriate examinations. Additional decongestion with diuretics resulted in general fatigue, increased HR, and decreased serum sodium level, and these did not improve even after diuretics were discontinued. Although administration of dobutamine improved his symptoms and normalized serum sodium level, sinus tachycardia still persisted. On day 34 after admission, he presented with acute decompensated HF with fever and diarrhea and required support with an intra-aortic balloon pump (IABP). Despite IABP support, his HR remained around 120 bpm. Administration of beta-blockers for HR reduction increased the PAWP and decreased SvO₂, whereas infusion of digoxin successfully lowered PAWP and HR, and raised SvO₂. His HR finally decreased to 80 bpm and he was weaned from IABP and inotropic support. We report here a case of severe heart failure with refractory sinus tachycardia, in which digoxin was effective in stabilizing the patient's hemodynamic parameters.