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Comparative effectiveness of digoxin and propranolol for supraventricular tachycardia in infants
Christoph P Hornik1, Patricia Y Chu, Jennifer S Li
11Department of Pediatrics, Duke University, Durham, NC 2Duke Clinical Research Institute, Durham, NC 3Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL.
Insights
Digoxin reduced supraventricular tachycardia recurrence in infants compared to propranolol. However, digoxin was linked to more frequent hypotension, indicating a trade-off in infant arrhythmia prophylaxis.
Area of Science:
- Pediatric Cardiology
- Neonatal Medicine
- Clinical Pharmacology
Background:
- Supraventricular tachycardia (SVT) is the most common infant arrhythmia.
- Antiarrhythmic medications are commonly used for SVT prophylaxis in infants.
- Optimal prophylactic medication for infant SVT remains unclear due to underpowered prior trials.
Purpose of the Study:
- To compare the efficacy and safety of digoxin and propranolol for SVT prophylaxis in infants.
- To determine if digoxin is associated with less frequent SVT recurrence than propranolol.
Main Methods:
- Retrospective cohort study utilizing a large clinical registry from Pediatrix Medical Group neonatal ICUs (1998-2012).
- Included infants discharged with SVT treated with either digoxin or propranolol, excluding specific conditions and multi-drug therapy.
- Cox proportional hazards models evaluated SVT recurrence, defined by need for adenosine or electrical cardioversion.
Main Results:
- 342 infants received digoxin and 142 received propranolol.
- Treatment failure incidence was 6.7/1,000 infant-days for digoxin vs. 15.4/1,000 infant-days for propranolol.
- Digoxin was associated with lower SVT recurrence (HR 1.97, 1.05-3.71) but higher rates of hypotension (39.4 vs 11.1/1,000 infant-days).
Conclusions:
- Digoxin demonstrated superior efficacy in preventing SVT recurrence compared to propranolol in hospitalized infants.
- Digoxin use was associated with a significantly higher incidence of hypotension.
- The choice between digoxin and propranolol for infant SVT prophylaxis involves balancing efficacy against the risk of hypotension.
Objectives:
Supraventricular tachycardia is the most common arrhythmia in infants, and antiarrhythmic medications are frequently used for prophylaxis. The optimal prophylactic antiarrhythmic medication is unknown, and prior randomized trials have been underpowered. We used data from a large clinical registry to compare efficacy and safety of digoxin and propranolol for infant supraventricular tachycardia prophylaxis. We hypothesized that supraventricular tachycardia recurrence is less common on digoxin when compared with propranolol.
Design:
Retrospective cohort study.
Setting:
Pediatrix Medical Group neonatal ICUs.
Patients:
Infants discharged from 1998 to 2012 with supraventricular tachycardia who were treated with digoxin or propranolol. We excluded infants discharged before completing 2 days of therapy, those with Wolff-Parkinson-White syndrome, structural heart defects (except atrial/ventricular septal defects and patent ductus arteriosus), and those started on multidrug therapy.
Measurements And Main Results:
We used Cox proportional hazards to evaluate supraventricular tachycardia recurrence, defined as need for adenosine or electrical cardioversion while exposed to digoxin versus propranolol, controlling for infant characteristics, inotropic support, supplemental oxygen, and presence of a central line. We identified 342 infants exposed to digoxin and 142 infants exposed to propranolol. The incidence rate of treatment failure was 6.7/1,000 infant-days of exposure to digoxin and 15.4/1,000 infant-days of exposure to propranolol. On multivariable analysis, treatment failure was higher on propranolol when compared with that on digoxin (hazard ratio, 1.97; 95% CI, 1.05-3.71). Hypotension was more frequent during exposure to digoxin versus propranolol (39.4 vs 11.1/1,000 infant-days; p < 0.001). There was no difference in frequency of other clinical adverse events.
Conclusions:
Digoxin was associated with fewer episodes of supraventricular tachycardia recurrence but more frequent hypotension in hospitalized infants relative to propranolol.
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