It must be emphasized that experts who have used this drug for over 20 years in patients with moderate to severe heart failure due to poor left ventricular function recognize clearly that when the drug is discontinued or the dose reduced, heart failure often recurs. Toxicity does not occur if the patient and a careful physician cooperate to prevent this.
B. Digitoxin
Supplied: Tablets: 0.1 mg, 0.15 mg, and 0.2 mg. Dosage: Initial and maintenance doses are the same: 0.05–0.1 mg daily; maximum 0.15 mg daily.
Digitoxin has a prolonged action and the effects can last four to six days. It is broken down in the liver and excreted in the gut. Omission of a dose or kidney failure has little effect on serum levels. Levels are not usually increased in patients with severe liver dysfunction. The main ‘‘disadvantage’’ is that when digitoxin toxicity occurs, it can persist for several days.
C. ACE Inhibitors and Angiotensin Receptor Blockers
The angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are very useful in the management of all grades of heart failure and represent a major medical breakthrough. They are considered vaso¬dilators and have been shown to save lives and prevent hospitalizations (see Table 2).

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